The US public health and social safety net are underfunded, creating gaps in services for those in need. During economic crises, natural disasters, or public health emergencies, the federal, state, and county structures and agencies we rely on to support public health needs are often able to get additional resources through emergency declarations by leveraging new federal or state spending designed to address immediate crises. By supplementing Medicaid matching funds or allocating new temporary spending at the federal level, an influx of resources can often help local communities address the pandemic or flood they are facing. Our local safety net is often supported by a combination of federal grant funds (e.g., grants to community clinics or local public health agencies) and federal‒ state partnerships like Medicaid and the Children’s Health Insurance Program that incentivize states and local programs to ramp up or expand programs using federal matching funds.
Now, our federalist model to address crises through local and state agencies is being eroded. New legislation (like HR1, the “Big, Beautiful Bill”) explicitly changes Medicaid and Supplemental Nutrition Assistance Program (SNAP) policy to reduce federal support and place a larger burden on states, while attitudes around the role of government in the Trump administration promise to dissolve the processes and structures we rely on to address state and local crises through prompt action administratively and legislatively. Cancelling federal grants to fund public health services and shrinking federal support for programs administered by the states is dangerous. If the Federal Emergency Management Agency, Centers for Disease Control and Prevention, and Centers for Medicare and Medicaid Services are unable to provide short-term funds or grant waivers or be nimble in the face of catastrophe, we will be flat-footed and ineffective when responding to new challenges.
HR1 places barriers on Medicaid and SNAP that will exacerbate disparities and leave us unable to respond to future pandemics, economic downturns, or other crises. Placing work requirements on Medicaid, reducing federal matching funds flowing into state Medicaid programs, and placing higher burdens on states to fund the shortfalls in Medicaid, SNAP, and other programs will make it that much harder to respond. We should anticipate more people falling through the cracks, with higher rates of uninsurance, poverty, and avoidable death. States with means might be able to fill some gaps, while creating others, because of their own budget situation. However, the impact will be worse in lower-income states with a higher reliance on federal support.
While the “obvious” response for many states is to cut programs, states that want to protect their residents and ensure stability will need to invest more state and local funds into protective and responsive systems for public health and social services. For example, California has a millionaire tax to fund county mental health services, and other states use taxes on specific goods to fund social services and education. States will need to establish larger rainy-day funds and budget surpluses to offset federal losses and address uncertainty.
In this issue’s special section, four research teams found that health and social policy changes driven by the urgency of a pandemic served to stabilize family incomes, insurance coverage, food availability, and nonprofit support organizations. These learnings should be emphasized in future policy decisions and deserve to be supported as long-term interventions and tools to improve economic and health conditions broadly, rather than only in the face of crisis. The articles explored existing policy mechanisms to improve the flow of resources to populations in need, which is far more efficient than creating new programs. All these programs are now gone because of the “unwinding” of the public health emergency; they represented a missed opportunity to address entrenched problems of poverty, uninsurance, and food insecurity.
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