Unfiltered

Belle

She's smart, and she makes good sharp points without getting shitty with people. I learn alot from her posts and from how she presents herself.

And I absolutely love how she hacks her way thru the bullshit of another bad-faith "argument" against Medicare For All.

Lying Liars

The Trump gang just makes shit up.

Medicaid work requirements built on invented evidence will harm the people they claim to help

The Centers for Medicare and Medicaid Services (CMS) has issued a new Interim Final Rule with comment period (IFC) implementing the Medicaid “community engagement” requirements included in H.R. 1. The IFC is fundamentally defective in both its substance and its analysis.

With respect to the analysis justifying the rule, the agency’s mandated Regulatory Impact Analysis (RIA) does not conform to the standards required of such analyses, as stipulated in Executive Order 12866 and the Office of Management and Budget (OMB) Circular A-4. It substitutes unsupported assumptions for the best available empirical evidence, counts speculative benefits while omitting well-documented costs, and produces estimates of coverage loss and federal savings that are inconsistent. With respect to the substance of the rule, CMS has added conditions, not required under the statute, that will make it even more difficult than the statute intended for people with mental illnesses and substance use disorders to retain coverage.

These are not technical shortcomings. This rule will determine whether millions of low-income Americans retain health insurance.

H.R. 1 requires certain Medicaid beneficiaries to document 80 hours a month of work or other qualifying activities to retain their eligibility for Medicaid. This IFC sets forth the rules defining which beneficiaries will and will not be exempt from this “community engagement” requirement. Under Executive Order 12866, economically significant regulatory actions, such as this IFC, must be accompanied by an RIA that assesses the costs and benefits of the action. In this case, the key parameter that will drive the costs and benefits of the regulatory action is how many people will become employed or otherwise community-engaged under the threat of losing Medicaid coverage. OMB requires agencies to base regulatory analyses on the best reasonably obtainable scientific, technical, and economic information. CMS acknowledges that it does not estimate this key behavioral response parameter from any such information. Instead, it assigns subjective weights to hypothetical scenarios. In its assessments of costs and benefits, CMS simply assumes that roughly one-third of affected beneficiaries will move into qualifying activities because of the requirement.

That assumption is wildly out of line with a substantial body of empirical evidence. Three distinct, robust lines of research, all consistent with one another, could have been used to estimate the likely impact of the requirement. First, studies of welfare-to-work programs, which condition receipt of cash benefits on employment, generally find small employment effects, with effects of under 5% even in scenarios where the work requirements in the programs are accompanied by childcare, transportation assistance, case management, and other supports—no such supports are included in the Medicaid rule. Second, studies of the Affordable Care Act’s Medicaid expansion—the converse of the new work requirements—find that gaining Medicaid has little or no effect on employment, implying that withdrawing coverage is unlikely to produce a substantial increase in engagement. Finally, studies of recent work requirements in the Supplemental Nutrition Assistance Program (SNAP) and Medicaid—including Arkansas’s Medicaid work requirements waiver—have found substantial coverage losses but no measurable increase in employment.

CMS’ assumption that one-third of those subject to the work requirement will become community-engaged is over six times greater than the largest estimate in any of these literatures. That assumption is an invention from which the agency mechanically generates its estimates of employment, earnings, costs, benefits, and government savings.

Because those estimates carry through the entire analysis, they generate further inconsistencies and distortions. The one-third engagement estimate leads CMS to predict that only about 3.1 million to 3.3 million people will lose Medicaid coverage annually. By contrast, the Congressional Budget Office (CBO) estimated that the statutory work requirement would reduce Medicaid enrollment by approximately 5.7 million people. Yet despite this much smaller headcount, CMS simultaneously projects approximately $350 billion in federal savings over 10 years—10% more than CBO’s estimate of $317 billion.

These figures are difficult to reconcile. If CMS expects fewer people to lose coverage but more money to be saved, it must implicitly assume that those losing coverage are dramatically more expensive than the beneficiaries reflected in CBO’s calculation. CMS’s numbers appear to imply average federal Medicaid spending of roughly $11,000 for each disenrolled person, compared with about $5,600 in CBO’s estimate.1 But Medicaid spending is highly concentrated. Many of the most expensive beneficiaries have serious health conditions that should qualify them for exemptions or temporary hardship protections. CMS does not adequately explain how its relatively small group of projected disenrollees can generate such large savings.

The implausible engagement assumption shows up again in the agency’s claims about the IFC’s benefits. Here, the agency claims that those shifted to engagement through the work requirement will become healthier from being induced into employment. The research basis CMS cites for the assumption that work makes you healthy is entirely based on associational studies of the health of workers and non-workers.

Healthier people are more likely to work. Poor health makes it harder to obtain and retain employment. Education, family resources, housing stability, and other factors affect both employment and health. Studies showing that employed people are healthier than unemployed people in no way establish that requiring a Medicaid beneficiary to work will make that person healthier. Indeed, the limited causal research, which relies on changes in retirement rules and other sources of plausibly exogenous variation, has produced mixed results: some studies find benefits from continued work, while others find that working harms health (for example, by increasing the risk of workplace injuries). There is no credible basis for assigning large health benefits to the hypothetical employment increases assumed to be generated by this rule.

At the same time, CMS largely omits the strongest causal evidence in this area: Medicaid coverage improves access to care, financial security, and health. Randomized and quasi-experimental studies have linked insurance coverage to improved treatment and, in several very credible studies, lower mortality. Other research shows that, at least for some populations, access to effective treatment can improve employment. Randomized studies of depression care, for example, have found increases in job retention, hours worked, and employment.

In other words, health coverage keeps people healthy and may help people work. Taking coverage away has direct harms and may make employment less likely. CMS’s analysis largely reverses this relationship: it assumes that work produces health while ignoring the possibility that health care produces both work and health.

The rule is especially poorly designed for people with mental illnesses and substance use disorders.

In the original statute, Congress provided exemptions for people with qualifying behavioral health conditions. CMS, however, would require many individuals to demonstrate not merely that they have a qualifying diagnosis, but that the condition significantly impairs their ability to comply with the work requirement.

Standard administrative reporting, such as medical claims, does not contain information on functional ability. That means that meeting the exemption will require a new miniature disability determination. States and clinicians will have to assess functional capacity, collect documentation, and decide whether a particular condition prevents compliance with 80 hours of monthly activities. States conduct such capacity determinations in conjunction with Social Security disability determinations; a costly, challenging process that provides applicants with important procedural protections (but nonetheless makes consequential errors).

Requiring such functional status determinations for people with mental illnesses and substance use disorders is particularly damaging because these conditions can impair memory, concentration, planning, and motivation. People with these conditions are likely to find it particularly difficult to navigate bureaucratic systems. The people most impaired may be those least able to prove that impairment.

The functional status criteria also fail to account for the fact that behavioral health conditions are chronic and recurring. A person with opioid use disorder, schizophrenia, bipolar disorder, or recurrent major depression may be stable enough to work for one month, experience a relapse the next, miss a reporting deadline, and lose the Medicaid coverage financing the treatment that helped maintain stability and employment. Current functioning while under treatment is not proof that an exemption is unnecessary. It may instead be evidence that treatment is working.

The statute particularly called for an exemption for those participating in substance use treatment programs. The CMS rule places very restrictive conditions on what participation means. In particular, it limits the exemption to care provided by nonprofit providers. However, nearly half of people receiving substance use treatment are served by for-profit organizations, and the share is particularly high among opioid treatment programs providing methadone. That means that patients receiving substance abuse treatment could lose exemption from work requirements because the providers who happen to be available in their communities are for-profit. That will be particularly damaging in rural areas and other places with thin treatment networks.

The IFC is defective in its substance and its design. A defensible Regulatory Impact Analysis would use the following information:

• The extensive causal literature to estimate employment effects,
• Quantify the health consequences of coverage loss, and
• Reconcile its enrollment estimates with its claimed federal savings.

A defensible rule under the statute would:

• Automatically identify behavioral health exemptions using claims, pharmacy, managed-care, and behavioral health agency data;
• Accept attestations from clinicians, case managers, and treatment programs;
• Recognize relapse and fluctuating functioning; and
• Provide rapid reinstatement when illness contributes to noncompliance.
• Instead, CMS’s analysis assumes away the central empirical question, inflates speculative benefits, omits documented harms, and then adds administrative barriers that are likely to exclude precisely the people Congress intended to protect.

WTF Are We Doing?

A full third of American adults say they've postponed getting care, or skipped it completely, because they were worried about the cost.

How long are we going to put up with this shit?

Belle

It's amazing - over a million Americans have been caught red-handed committing fraud, but I guess the supremely sympathetic Trump DOJ just couldn't bring themselves to indict anybody for it?

Won't wonders never cease.

Dr Jess

An Exchange

Canada:

I just finished off a couple of American energy drinks. At first, I was happy to get away from the caffeine restrictions of the nanny state in Ottawa, but honestly, I'm really fucked up right now, and it feels like I'm completely dissociating. How do you people live like this?

America:

It's what we have instead of healthcare.

Worth Repeating

Today's Belle

The Republican Healthcare Plan:

1. Don't get sick
2. If you get sick, die quickly

Schumer seems incapable of understanding that the old way of doing business in Congress is a near-futile exercise these days. He keeps trying to finesse things, and while that's a good way to go under "normal" circumstances, we haven't been under normal circumstances for quite a while now. We have to be able to play a little straight up smashball, because these MAGA fanatics are more interested in being scalp-takers than they are in being calm and deliberate statesmen.

Dr Noc

BKjr is going to cost people their lives.

Today's Belle

She's not usually as bold as this.

⬆︎114%

Today's Belle

Republicans are not pro-life. It's a gimmick - nothing but political theater and pretense.

Today's Robert

"... and if the lights go out for a while, fuck it. So be it. The truth shines brightest in the dark anyway."

Welcome

...to late-stage capitalism.

It's a fight between the New Robber Barons, who see you as nothing but a revenue opportunity, versus the woke mind virus that wants you to get help when you need it so your loved ones can get what they need to go on living.

Science, Bitches

Up until about 1840, half of all humans died by the time they turned 30. Over the next 60 years, we managed to add about 5 years to that, thanks to people like Pasteur and Lister.

So, in 40,000 years of human "civilization", average lifespans increased by about 17%.

In the last 125 years, that average has doubled. And it's mostly because infant mortality has fallen off a cliff (it's the vaccines, stupid), and better diagnostics, and miracle drugs, and a higher overall health consciousness, and and and.

But while we don't enjoy the longevity of many countries around the world, we're only a few years behind.

We're still behind though, and that doesn't make sense.

We used to be told it was because we're such high-achievers we put a lot of extra stress on ourselves, and that gives us ulcers and hypertensive problems, etc. But other places haven't exactly slouched in the go-getter department. So maybe it's because (eg) the French have a glass of red wine with dinner, even though French cuisine is generally loaded with butter and sugar and heavy cream and fat. And the Japanese were outliving us because they ate lots of fish and plain rice and seaweed. And everybody walked more than we did.

Nope. It's healthcare.

Pretty simply, when people have somebody looking after them - regular checkups, and proper meds, and preventive visits to the dentist, and all the stuff they're not stupid enough to put into the hands of the bean-counters and gatekeepers, THEY LIVE LONGER.

Gee - whooda thunk it, huh?

So, of course, let's turn it all over to Bobby Brainworm. What's the worst that could happen?

Big Butt-Ugly Bamboozle

Small rural hospitals are about to dry up and blow away.

The further this goes, the more urgent it becomes to start moving the whole thing to a Single Payer system.

Unfortunately, the insurance carriers and the pharmacy benefits management companies have the ability to buy more coin-operated politicians to stop efforts to make the thing work.

We have to stand up and spit in their eye.



Rural Reckoning | Beset by constant budget pressures, rural hospitals serve patients — and local economies

Colorado’s rural hospitals are teetering on the edge of financial collapse, burdened by rising costs, shrinking reimbursements and a growing list of state and federal regulations, according to the Colorado Hospital Association.

In Colorado, half of the 88 acute care hospitals are in rural or frontier counties.

The difference between rural and frontier healthcare depends on population density. A rural county in healthcare is defined as a non-metropolitan area that does not contain a city with a population of more than 50,000 people. A frontier county has a population density of six or fewer people per square mile.

Frontier counties represent the most sparsely populated areas within the broader category of rural counties, according to the Colorado Department of Health Care Policy and Financing.

In Colorado’s 64 counties, 24 of them meet rural designation requirements, while 23 are labeled as frontier.

These healthcare woes quickly become a major issue for Minority Whip Sen. Cleave Simpson, a Republican from Alamosa who said he originally entered politics because he is worried about rural water rights.

“I live in a community where just providing basic services at my rural hospital in particular always puts them under pressure and on the very near cusp of complete collapse,” said Simpson, who became more worried as he got more educated on the obstacles providers face. “As a state, we just can’t afford to have that happen. In my communities, individuals can’t afford for that to happen.”

Joe Thiene, the CEO of the Southwest Health System, a 20-bed critical access hospital in Cortez, said it serves as a corridor between Durango and Utah, noting that, without it, a resident would have to travel over a mountain pass to access higher-level care.

“The remoteness is very real for us,” Thiene said.

On June 23, Theine had joined a panel discussion on rural healthcare during the annual Western Governors’ Conference in Santa Fe.

Janessa Graves, of the Rural Health Research Center in Washington, and Christina Campos, of Guadalupe County Hospital, a 10-bed general acute care facility in Santa Rosa, N.M., joined Thiene. The three panelists agreed that, regardless of a rural hospital's location in the U.S., it is likely struggling to survive.

An economic driver

Besides providing critical healthcare, Thiene said the Cortez hospital is an economic driver, noting that it is the second-largest employer in the area.

“We’re larger than the school districts,” he said. “We’re larger than the local governments within the county and municipalities. And so, I think about what we’re delivering to the community in terms of health and vibrancy. It’s more than just the impact on the individuals and their health; it shouldn’t matter where you live in terms of health outcomes.”

According to the Colorado Hospital Association’s latest numbers from 2023, rural hospitals in Colorado:

• Cared for 34,000 inpatients

• Delivered 4,860 babies

• Stabilized 310,000 people

• Cared for 500,000 patients

• Employed 16,000 employees

• Provided $6.6 billion in indirect economic impact

Thiene said rural hospitals also offer higher-paying jobs in the area.

“So, when you look at the median income for healthcare workers that we pay, it’s much higher than the average household income for families that are living in the area that we serve,” he said. “And so, as rural healthcare goes, or as our hospital goes as an employer, so goes a lot of second and third order impacts in terms of the local economy.”

Theine said employees do not just mean doctors and nurses — they also include people in food services, janitorial support and other fields that are required to keep the hospital open and meet regulatory requirements.

The problem, as outlined by Campos, is that people do not understand the cost of keeping the doors open at a rural hospital. The fees are fixed and rarely fluctuate, she stressed, noting that it costs about $40,000 per day to keep the doors open in Guadalupe County.

In Cortez, Theine said the fixed amount is approximately $215,000 per day, regardless of whether the hospital sees one or 200 patients. The hospital is open 24/7, he said, which means that x-ray machines, heart monitors, and all equipment must be ready to use at any moment — day or night and staff must be available to operate it.

While hospitals face fixed costs to stay open, it doesn’t mean the funding is stable, making it a balancing act to maneuver between state and federal funding streams, the health officials said.

Workforce shortages have also become another obstacle to managing rural healthcare facilities. The lack of affordable housing and amenities deters many from relocating to work in a rural hospital, Theine said.

That has led to hospital officials to get more creative, recruiting and educating students out of high school with the hopes that, after they get their education, they may return to work where they grew up.

In contrast, Theine said doctors and nurses who come to a hospital for residency are less inclined to stay.

The hospital in Cortez is currently working to partner with community colleges, four-year programs, local universities, and others, aimed at keeping local students interested in pursuing their goals.

Medicaid worries

As Congress recently adopted the Trump administration's budget bill, healthcare providers are worried about its implications for Medicaid.

The debate comes as Medicaid costs continue to rise under the Affordable Care Act. Forty states, including Colorado, and Washington D.C. have expanded Medicaid eligibility. Critics have argued that reforms are necessary to address increasing costs and ensure the long-term sustainability of the program. They also pointed to the nation’s $36 trillion debt, as well as the federal government's $1.8 trillion deficit from the previous year.

One study, from a group called Paragon, noted that the federal government has paid for an increasingly larger share of Medicaid expenses, with the “Obamacare” expansion responsible for much of that shift. The group claimed the expansion led to Medicaid resources being diverted from children and individuals with disabilities to “able-bodied, working-age adults.”

The new categories of eligible enrollees receive a much higher federal reimbursement rate, leading to a diversion of resources away from traditional Medicaid enrollees, particularly low-income children and people with disabilities,” a “near quadrupling” of Medicaid’s “improper payments” and a “surge of spending” that contributed to the growing federal deficit, the group said.

Another study said states employed strategies to “artificially inflate their Medicaid spending to maximize the federal reimbursement.”

Republicans also defended the Medicaid cuts as only affecting immigrants staying in the country unlawfully who shouldn’t be receiving the subsidies to begin with.

Supporters of Medicaid expansion have argued it was necessary to finally provide health insurance to millions of Americans. Democrats now say millions would lose coverage if states do not step in to fill the gaps.

Due to the Medicaid cuts, Gov. Jared Polis is currently considering calling a special session to convene the state legislature, which will have to review healthcare costs in a year that already started with a $1 billion budget deficit.

Polis told Colorado Politics that the state of rural healthcare is in the "reactive" stage, meaning action has to be taken immediately.

"This is directly because of changes federally," Polis said. "There's things in (the federal budget) that I like — no taxing on tips is good. But, any cuts to healthcare affects everybody. The big hospitals in Colorado Springs and Denver won't be put out of business, but rural hospitals cannot survive."

Like it or not, Campos said Medicaid is the system in place and it’s what rural hospitals rely on, noting that if significant cuts continue, New Mexico could see up to eight hospitals go “belly up” in the coming year.

“Because given these dramatic cuts, we will lose rural health care delivery providers,” she claimed.

Thiene said the Medicaid dilemma is that the responsibility has to be balanced between the federal and state governments.

“If we don’t have that in the right balance, then when we travel across our great nation, we're not gonna be able to rely on healthcare being where we go,” he said. “And that's part of that federal responsibility that we need to ask our elected officials to uphold it.”

Today's Belle

It's not good now, it wasn't much better before, and it's about to get a lot worse.

• 432 hospitals are already struggling, at risk of going under
• 46% of hospitals in rural areas are underwater
• the hospital in McCook NE has announced it's closing soon
• 33 hospitals in Louisiana are teetering on the brink

And all that was happening before the Big Butt-Ugly Bamboozle gets around to cutting a trillion dollars out from under them.

Anyone who's not making north of about $400K, or isn't insured up around the platinum level will be negatively affected. And even then, shortages of care - care centers, services, and caregivers - will impact everybody.

The hospitals in areas that voted Republican by 2-to-1 and 3-to-1 margins are likely to flat-out disappear starting very soon, creating (or worsening) Maternity Care Deserts, and Chemo Deserts, and Dialysis Deserts, and Elder Care Deserts, and and and.

Maybe we should begin planning for "care shortages", and come up with something like Triage Protocols so clinicians can deal with the problems they're likely to encounter because of their ethical obligation to treat the patient in front of them regardless of that patient's ability to pay.

• Alabama: Alabama Care
• Alaska: DenaliCare
• Arizona: Arizona Health Care Cost Containment System (AHCCCS)
• Arkansas: Arkansas Medicaid/Healthcare
• California: Medi-Cal
• Colorado: Health First Colorado
• Connecticut: HUSKY Health/Connecticut Medicaid
• Delaware: Diamond State Health Plan/Delaware Medicaid
• Florida: Statewide Medicaid Managed Care (SMMC)
• Georgia: Georgia Medicaid
• Hawaii: Med-QUEST
• Idaho: Idaho Medicaid
• Illinois: Illinois Medicaid
• Indiana: Hoosier Healthwise
• Iowa: Iowa Medicaid
• Kansas: KanCare
• Kentucky: Kentucky Medicaid
• Louisiana: Louisiana Medicaid
• Maine: MaineCare
• Maryland: Maryland Medical Assistance Program
• Massachusetts: MassHealth
• Michigan: Michigan Medicaid
• Minnesota: Minnesota Health Care Programs
• Mississippi: Mississippi Medicaid
• Missouri: MO HealthNet
• Montana: Montana Medicaid
• Nebraska: Nebraska Medicaid
• Nevada: Nevada Medicaid
• New Hampshire: New Hampshire Medicaid
• New Jersey: New Jersey FamilyCare
• New Mexico: Turquoise Care
• New York: New York State Medicaid
• North Carolina: North Carolina Medicaid
• North Dakota: North Dakota Medicaid
• Ohio: Ohio Medicaid
• Oklahoma: Oklahoma Medicaid
• Oregon: Oregon Health Plan
• Pennsylvania: Pennsylvania Medicaid
• Rhode Island: Rhode Island Medicaid
• South Carolina: South Carolina Medicaid
• South Dakota: South Dakota Medicaid
• Tennessee: Tennessee Medicaid
• Texas: STAR
• Utah: Utah Medicaid
• Vermont: Vermont Medicaid
• Virginia: Virginia Medicaid
• Washington: Washington Apple Health
• West Virginia: West Virginia Medicaid
• Wisconsin: Wisconsin Medicaid
• Wyoming: Wyoming Medicaid

American Death Cult

Trump's gang is putting people's lives at risk.

The question is: Why?

• I can't say with any great conviction that the whole thing is malevolent, but that shouldn't be dismissed
• Maybe the cult effect is driving people to do whatever they think is fashionable at the moment
• Group psychosis is always an option

But there's a certain element of "branding" at work, and I think that's the gist of it. ie: Trump's brand is 'A', so people migrate to him for a variety of reasons, not the least of which is thinking they can wield power and get a good-sized paycheck out of it. And whether they actually align with his "thinking" or not is of no great concern to them.

And "the greater good" be damned.

The Kids Are Not Alright

If Republicans were at all interested in the kids - their physical, emotional, intellectual wellbeing - they wouldn't be attacking everything that supports them and their families.

It's been said, and it's been said again, and again, but it's not really getting through, so here it is one more time:

Republicans love to stomp around yelling about god and Jesus and how precious the little darlings are (their little darlings anyway) while they ignore what their lord and savior said as long as it doesn't quite jibe with the politics of the moment.

Like this from Matthew, chapter 18 verses 2-6

“‘Truly I tell you, unless you change and become like little children, you will never enter the kingdom of heaven. Therefore, whoever takes the lowly position of this child is the greatest in the kingdom of heaven. If anyone causes one of these little ones to stumble, it would be better for them to have a large millstone hung around their neck and to be drowned in the depths of the sea.'”

They just don't fucking care.

The Trump Administration’s War on Children

The administration is quietly putting America’s children at risk by cutting funds and manpower for investigating child abuse, enforcing child support payments, providing child care and much more.

The clear-cutting across the federal government under President Donald Trump has been dramatic, with mass terminations, the suspension of decades-old programs and the neutering of entire agencies. But this spectacle has obscured a series of moves by the administration that could profoundly harm some of the most vulnerable people in the U.S.: children.

Consider: The staff of a program that helps millions of poor families keep the electricity on, in part so that babies don’t die from extreme heat or cold, have all been fired. The federal office that oversees the enforcement of child support payments has been hollowed out. Head Start preschools, which teach toddlers their ABCs and feed them healthy meals, will likely be forced to shut down en masse, some as soon as May 1. And funding for investigating child sexual abuse and internet crimes against children; responding to reports of missing children; and preventing youth violence has been withdrawn indefinitely.

The administration has laid off thousands of workers from coast to coast who had supervised education, child care, child support and child protective services systems, and it has blocked or delayed billions of dollars in funding for things like school meals and school safety.

These stark reductions have been centered in little-known children’s services offices housed within behemoth agencies such as the Department of Health and Human Services and the Department of Justice, offices with names like the Children’s Bureau, the Office of Family Assistance and the Office of Juvenile Justice and Delinquency Prevention. In part because of their obscurity, the slashing has gone relatively overlooked.

“Everyone’s been talking about what the Trump administration and DOGE have been doing, but no one seems to be talking about how, in a lot of ways, it’s been an assault on kids,” said Bruce Lesley, president of advocacy group First Focus on Children. He added that “the one cabinet agency that they’re fully decimating is the kid one,” referring to Trump’s goal of shuttering the Department of Education. Already, some 2,000 staffers there have lost or left their jobs.

The impact of these cuts will be felt far beyond Washington, rippling out to thousands of state and local agencies serving children nationwide.

The Department of Education, for instance, has rescinded as much as $3 billion in pandemic-recovery funding for schools, which would have been used for everything from tutoring services for Maryland students who’ve fallen behind to making the air safer to breathe and the water safer to drink for students in Flint, Michigan. The Department of Agriculture, meanwhile, has canceled $660 million in promised grants to farm-to-school programs, which had been providing fresh meat and produce to school cafeterias while supporting small farmers.

At the Department of Health and Human Services, Robert F. Kennedy Jr., the agency’s secretary, has dismissed all of the staff that had distributed $1.7 billion annually in Social Services Block Grant money, which many states have long depended on to be able to run their child welfare, foster care and adoption systems, including birth family visitation, caseworker training and more. The grants also fund day care, counseling and disability services for kids. (It is unclear whether anyone remains at HHS who would know how to get all of that funding out the door or whether it will now be administered by White House appointees.)

Head Start will be especially affected in the wake of Kennedy’s mass firings of Office of Head Start regional staff and news that the president’s draft budget proposes eliminating funding for the program altogether. That would leave one million working-class parents who rely on Head Start not only for pre-K education but also for child care, particularly in rural areas, with nowhere to send their kids during the day.

Some local Head Start programs are already having to close their doors, and many program directors are encountering impediments to spending their current budgets. When they seek reimbursement after paying their teachers or purchasing school supplies, they’re being directed to a new “Defend the Spend” DOGE website asking them to “justify” each item, even though the spending has already been appropriated by Congress and audited by nonpartisan civil servants.

Next on the chopping block, it appears, is Medicaid, which serves children in greater numbers than any other age group. If Republicans in Congress go through with the cuts they’ve been discussing, and Trump signs those cuts into law, kids from lower- and middle-class families across the U.S. will lose access to health care at their schools, in foster care, for their disabilities or for cancer treatment.

The Trump administration has touted the president’s record of “protecting America’s children,” asserting in a recent post that Trump will “never stop fighting for their right to a healthy, productive upbringing.” The statement listed five examples of that commitment. Four were related to transgender issues (including making it U.S. government policy that there are only two sexes and keeping trans athletes out of women’s sports); the other was a ban on COVID-19 vaccine mandates at schools that receive federal funding.

The White House, and multiple agencies, declined to respond to most of ProPublica’s questions. Madi Biedermann, a Department of Education spokesperson, addressed the elimination of pandemic recovery funding, saying that “COVID is over”; that the Biden administration established an “irresponsible precedent” by extending the deadline to spend these funds (and exceeding their original purpose); and that the department will consider extensions if individual projects show a clear connection between COVID and student learning.

An HHS spokesperson, in response to ProPublica’s questions about cuts to children’s programs across that agency, sent a short statement saying that the department, guided by Trump, is restructuring with a focus on cutting wasteful bureaucracy. The offices serving children, the statement said, will be merged into a newly established “Administration for Healthy America.”

Programs that serve kids have historically fared the worst when those in power are looking for ways to cut the budget. That’s in part because kids can’t vote, and they typically don’t belong to political organizations. International aid groups, another constituency devastated by Trump’s policy agenda, also can’t say that they represent many U.S. voters.

This dynamic may be part of why cuts on the health side of the Department of Health and Human Services — layoffs of doctors, medical researchers and the like — have received more political and press attention than those on the human services side, where the Administration for Children and Families is located. That’s where you can find the Office of Child Support Services, the Office of Head Start, the Office of Child Care (which promotes minimum health and safety standards for child care programs nationally and helps states reduce the cost of child care for families), the Office of Family Assistance (which helps states administer direct aid to lower-income parents and kids), the Children’s Bureau (which oversees child protective services, foster care and adoption) and the Family and Youth Services Bureau (which aids runaway and homeless teens, among others).

All told, these programs have seen their staffs cut from roughly 2,400 employees as of January to 1,500 now, according to a shared Google document that is being regularly updated by former HHS officials. (Neither the White House nor agency leadership have released the exact numbers of cuts.)

Those losses have been most acutely felt in the agency’s regional offices, five out of 10 of which — covering over 20 states — have been closed by the Trump administration. They were dissolved this month without notice to their own employees or to the local providers they worked with. It was these outposts that had monitored Head Start programs to make sure that they had fences around their playgrounds, gates at the top of their stairs and enough staffing to keep an eye on even the most energetic little ones. It was also the regional staff who had helped state child support programs modernize their computer systems and navigate federal law. That allowed them, among other things, to be able to “pass through” more money to families instead of depositing it in state coffers to reimburse themselves for costs.

And it was the regional staff who’d had the relationships with tribal officials that allowed them to routinely work together to address child support, child care and child welfare challenges faced by Native families. Together, they had worked to overcome sometimes deep distrust of the federal government among tribal leaders, who may now have no one to ask for help with their children’s programs other than political appointees in D.C.

In the wake of the regional office cuts, local child services program directors have no idea who in the federal government to call when they have urgent concerns, many told ProPublica. “No one knows anything,” said one state child support director, asking not to be named in order to speak candidly about the administration’s actions. “We have no idea who will be auditing us.”

“We’re trying to be reassuring to our families,” the official said, “but if the national system goes down, so does ours.”

That national system includes the complex web of databases and technical support maintained and provided by the Office of Child Support Services at HHS, which helps states locate parents who owe child support in order to withhold part of their paychecks or otherwise obtain the money they owe, which is then sent to the parent who has custody of the child. Without this federal data and assistance, child support orders would have little way of being enforced across state lines.

For that reason, the Trump administration is making a risky gamble by slashing staffing at the federal child support office, said Vicki Turetsky, who headed that office under the Obama administration. She worries that the layoffs create a danger of system outages that would cause child support payments to be missed or delayed. (“That’s a family’s rent,” she said.) The instability is compounded, she said, by DOGE’s recent unexplained move to access a highly confidential national child support database.

But even if the worst doesn’t come to pass, there will still be concrete consequences for the delivery of child support to families, Turetsky said. The staff members who’ve been pushed out include those who’d helped manage complicated, outdated IT systems; without updates, these programs might over- or undershoot the amount of child support that a parent owes, misdirect the money or fail to give notice to the dad or mom about a change in the case.

When Liz Ryan departed as administrator of the Department of Justice’s juvenile division in January, its website was flush with opportunities for state and local law enforcement as well as nonprofits to apply for federal funding for a myriad of initiatives that help children. There were funds for local police task forces that investigate child exploitation on the internet; for programs where abused children are interviewed by police and mental health professionals; and for court-appointed advocates for victimized kids. Grants were also available for mentoring programs like Big Brothers Big Sisters and the Boys & Girls Clubs of America.

But the Trump administration removed those grant applications, which total over $400 million in a typical year. And Ryan said there still hasn’t been any communication, including in what used to be regular emails with grant recipients, many of whom she remains in touch with, about whether this congressionally approved money even still exists or whether some of it might eventually be made available again.

A spokesperson for the Office of Justice Programs within the DOJ said the agency is reviewing programs, policies and materials and “taking action as appropriate” in accordance with Trump’s executive orders and guidance. When that review has been completed, local agencies and programs seeking grants will be notified.

Multiple nonprofits serving exploited children declined to speak on the record to ProPublica, fearing that doing so might undermine what chance they still had of getting potential grants.

“Look at what happened to the law firms,” one official said, adding that time is running out to fund his program’s services for victims of child abuse for the upcoming fiscal year.

“I never anticipated that programs and services and opportunities for young people wouldn’t be funded at all by the federal government,” Ryan said, adding that local children’s organizations likely can’t go to states, whose budgets are already underwater, to make up the funding gap. “When you look at this alongside what they’re doing at HHS and the Department of Education and to Medicaid, it’s undercutting every single effort that we have to serve kids.”