The landscape of healthcare in the United States has been shaped over decades of federal legislation and reform since the early 1900s. Last summer, the 2025 federal budget reconciliation act, better known as the One Big Beautiful Bill Act (OBBBA), was signed into law, introducing expansive changes to several federal agencies and programs, including health and social programs like Medicaid and SNAP.
The effects of federal healthcare policy are frequently discussed in terms of changes to insurance coverage, healthcare costs, and access to care. Yet these policies also have broader implications for public health systems since state and local health departments, community health centers, and hospitals generally rely on federal support and oversight to provide preventative and community-based services, and thus their capacity to meet local health needs can also be affected when federal healthcare initiatives change.
When priorities shifted to “maximize efficiency and productivity” within the federal workforce, the Department of Health and Human Services downsized by 20,000 employees across several subagencies that oversee critical public health services, including the Centers for Disease Control and Prevention, Food and Drug Administration, and the National Institutes of Health. These reductions led to the loss of entire programs and services, and their impacts have reverberated across communities, like the dissolution of the Missouri Immunization Coalition, who previously coordinated efforts to raise vaccination rates in their state. For many agencies, federal funding supplements state and local resources and makes it possible to continue programs that might otherwise be difficult to sustain. Therefore, when funding is reduced, redirected, or otherwise interrupted by new policies or requirements, public health agencies often have to make difficult decisions about which services to maintain. In June 2026, the Department of Health and Human Services terminated millions of dollars in teen pregnancy prevention grants, putting organizations like Emdolen Wisconsin, who oversees a program that educates teens on how to navigate the healthcare system, at risk as this might only be the first funding loss for their program following new federal guidance.
The Congressional Budget Office (CBO) projected a $1.1 billion reduction in federal spending based on changes to health programs included in the OBBBA. They also estimated that the bill’s new work requirements and more frequent eligibility checks for Medicaid could cause the number of people without health insurance to increase by 10 million by 2034. Additionally, stricter pre-enrollment verification procedures for the Affordable Care Act healthcare marketplace are also expected to contribute to the rise in uninsured individuals.
Together, these changes will drastically reduce access to vital services, including primary and preventive care. We have already seen what happens when access to these services is limited; individuals may delay treatment until conditions become more serious, increasing emergency department use. This increased reliance on acute care services can further strain hospitals, community clinics, and other safety-net providers already stretched thin by growing workforce shortages and persistent financial constraints.
While the impacts on the healthcare system are more obvious, the invisibility of public health can make it difficult for people to recognize how far-reaching these changes are. Moreover, disruptions to the public health system may take longer to be felt. The crux of public health is prevention, so by nature, the stronger a public health system is, the less visible the outcomes it prevents become. As true as that may be, this line of thinking has put the state of public health in a negative feedback loop–it’s important until it’s not, and we tear down the “unnecessary” infrastructure only to realize it was actually the foundation that was holding the whole house together.
Public health systems require continuous investment, but funding fluctuations erode critical public health infrastructure that has to be reinstated every time we find ourselves in another period of public health urgency. It’s incredible that public health has been able to accomplish anything under these conditions, but how long will this system hold up?
The instability of public health infrastructure feels like its own public health issue at this point. Now that we’re in yet another lean era, we can use this opportunity to find a way out of the “boom-and-bust” cycle that we’ve been through before. As we scale down programs and restructure initiatives, we should also consider how to use existing funds to build a reliable, sustainable path forward from within, so we’re no longer bracing ourselves for impact at every turn of the administration. Certainly this would require a complete overhaul of the existing infrastructure, but if we’re going to rebuild it anyway, let’s try something new for once.
About the Author
- Nichole Fusilier, MS, MPH, is a researcher at the Center for Public Health Systems. Their expertise includes evaluating community mental health programs, analyzing the impact of healthcare policies, and conducting research aimed at improving community health outcomes. Nichole is committed to advancing the well-being of individuals and their communities and reducing health disparities through research and policy advocacy.
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