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Government Shutdown Effects on Public Health: Lessons from the 2025 and 2018-2019 Closures Catherine Jones Learn about the government shutdown effects on public health, with insights from the 2025 and 2018-2019 closures. When the federal government shuts down, it exposes vulnerabilities in our public health ecosystem. It also brings to light the critical role state and territorial health departments play to protect the health of their jurisdictions. While the political dynamics behind each shutdown may vary, the consequences are unfailingly disruptive. Some federal agencies and programs continue under mandatory or advance appropriations, but the day-to-day machinery that keeps the federal public health system functioning — workforce, oversight, and technical assistance — is impacted. Federal employees from shuttered agencies are either furloughed or required to work without pay if their roles are deemed essential to public safety, as with certain functions of HHS and FDA, among others. The effects of a shutdown can be temporary or long-lasting. In the past, Congress enacted guardrails to reduce the harm of future funding lapses, but the unpredictable nature of each shutdown ensures that disruption, loss, and hardship follow. A comparison of the 2025 and 2018-2019 shutdowns displays this impact — with the 2025 impasse becoming the longest shutdown in U.S. history, surpassing the 35-day record set during the December 2018 to January 2019 closure. Key Differences Between the Shutdowns The 2018-2019 shutdown, which was sparked over a funding fight for the U.S-Mexico border wall, spared HHS because the FY2019 Labor-HHS-Education Appropriations Act had already been enacted before the funding lapse. As a result, core public-health agencies — including CMS, CDC, HRSA, and SAMHSA — continued operating. However, the programs funded through the Agriculture-FDA appropriations bill (e.g., SNAP, WIC, and FDA) were impacted, but the disruptions were somewhat contained: FDA paused some food and drug inspections, while SNAP and WIC administrators worked to stretch timing buffers to sustain benefits. The 2025 shutdown, by contrast, impacted HHS. Disputes over the Continuing Appropriations and Extensions Act, 2026, (H.R. 5371), also known as a continuing resolution (CR) — compounded by an acrimonious stalemate over extending the Affordable Care Act premium tax credits (analyses show premiums could more than double in 2026 without extensions) and reversing Medicaid cuts in the One Big Beautiful Bill — placed health care directly in the shutdown’s epicenter. After 14 failed attempts to move the CR in the Senate, the measure was revised to extend federal funding through Jan. 30, 2026, and to reverse the Reductions in Force (RIFs) enacted during the lapse in appropriations. This CR was combined with three additional minibus appropriations packages, which included the Agriculture-FDA bill that funds SNAP and WIC through FY2026. On Nov. 10, the Senate narrowly mustered the 60 votes needed for passage, with eight Democratic senators joining in support. The bill then cleared the House on Nov. 12 with a 222-209 vote, and President Trump signed it the same day. The result of the 43-day shutdown was a deeper and more systemic breakdown. Furloughs and RIFs swept across agencies. Staffing gaps impacted CDC, SAMHSA, and CMS operations, while lawsuits proliferated over withheld pay, suspended contracts, and SNAP payment distribution. As of now, ACA subsidies remain unresolved, and the full repercussions of the 2025 shutdown continue to emerge. A Closer Look at the Shutdown Impacts Furloughs In 2025, the HHS contingency plan anticipated furloughing roughly 41% of its workforce, with CDC and NIH hit hardest — about 64% and 75% of staff, respectively. During the 2018-2019 shutdown, about 48% of HHS staff were furloughed, with CDC at 61% and NIH at 76%. After the 2018-2019 shutdown, Congress enacted the Government Employee Fair Treatment Act of 2019, ensuring that all furloughed federal employees receive retroactive back pay once operations resume. The current CR provides a provision requiring the payment of federal employees who are furloughed or excepted during the lapse. Government contractors, unlike direct federal employees, are not guaranteed back pay after shutdowns. RIFs During the 2025 shutdown, CDC issued more than a thousand layoff notices, some later rescinded, while SAMHSA reported significant workforce losses. There were no RIFs during the 2018-2019 shutdown. In AFGE v. Donald J. Trump, federal-worker unions challenged the administration’s issuance of mass layoff notices during the 2025 shutdown, arguing that RIFs during a funding lapse violate the Antideficiency Act and are “arbitrary and capricious.” A federal judge issued a preliminary injunction blocking further RIFs for hundreds of employees. This case is currently ongoing. To note, as part of the revised aforementioned CR, RIFs issued during this shutdown were reversed, returning to status quo workforce levels prior to the lapse of appropriations. WIC WIC entered October 2025 with funds from Section 32, providing $300 million as a bridge. Nationally, on average, WIC (a discretionary program) needs about $150 million per week to serve approximately 7 million women, infants, and children. To support access, several states tapped emergency funds and reallocated resources to food banks. In early November, the Trump Administration transferred $450 million from unused customs revenue to fund WIC. During the 2018-2019 shutdown, WIC continued to operate without gaps using prior-year funds. SNAP Roughly 42 million Americans currently rely on SNAP benefits. SNAP is considered mandatory spending, which allows payments to continue temporarily during a shutdown, but when a lapse exceeds 30 days, disruption risk escalates. During the 2025 shutdown, EBT payment delays triggered widespread litigation. In Coalition of States v. U.S. Department of Agriculture, over 25 states sued USDA for suspending benefits despite available contingency funds, citing violations of the Food and Nutrition Act and the Administrative Procedure Act. Federal courts issued temporary restraining orders protecting millions of beneficiaries. The administration appealed to the Supreme Court to halt payments, and the Court granted the request. During the 2018-2019 shutdown, SNAP participants received benefits in December 2018 and January 2019. February benefits were also distributed in late January to avoid disruptions; these were not additional benefits. Tribal Health In 2025, the Indian Health Service remained open due to FY2026 enacted advance appropriations. This funding was in part a reaction to the dire consequences of the 2018-2019 shutdown in which the Tribal and Urban health programs reported having to limit health care services and resources, due to Indian Health Service employees having to work without pay or being furloughed. Unique Implications of the 2025 Shutdown As previously noted, because Congress fully funded HHS in 2018-2019 there was minimal impact on public health programs. However, the length and scope of the 2025 shutdown did impact HHS directly. For example: Mental health: Mental and behavioral health access contracted sharply as SAMHSA’s state-support network lost nearly two-thirds of its staff, due to shutdown RIFs as well as earlier rounds of layoffs and retirements. At-home care and telehealth: During the 2025 government shutdown, hospitals nationwide faced delayed Medicare reimbursements and the temporary suspension of hospital-at-home programs, which had become vital for managing capacity during workforce shortages. Telehealth expansion and remote monitoring efforts were also paused, causing many patients to pay out of pocket. U.S. territories: The pause on SNAP and the Nutrition Assistance Program (NAP) funding in November had disproportionate impacts on the U.S. territories, as higher percentages of their populations depend on SNAP and NAP (20%-40%). In three territories, legislatures passed bills to fund partial or full SNAP and NAP benefits for November. Implications for the Future of Public Health The 2025 shutdown underscored that lapses in government funding disrupt the public health ecosystem. A fully functioning system relies on steady collaboration from federal, state, local, and tribal health departments. The depth of the 2025 crisis has ignited bipartisan discussion about structural fixes to prevent governing by brinkmanship. Proposed congressional legislation includes bills to stabilize federal pay with automatic funding, contain congressional travel and adjournment until appropriations are complete, guarantee pay for federal workers and contractors, prevent disruption to SNAP and WIC programs, and ensure reimbursement to states. Padding Block - Large Related Contnet - Blog - Government Shutdown Effects on Public Health article yes

Federal, State, and Stakeholder Perspectives on the Rural Health Transformation Fund Perspectives on the Rural Health Transformation Fund Catherine Jones Explore federal, state, and stakeholder perspectives on the Rural Health Transformation Fund, shared at a discussion hosted by ASTHO and Cornerstore Government Affairs teams. In early July, ahead of final votes on the One Big Beautiful Bill Act (full text H.R.1), Senate Majority Leader John Thune (R-SD), joined by Senators Susan Collins (R-ME) and Lisa Murkowski (R-AK), secured a $50 billion funding line for a new Rural Health Transformation Program (RHTP). This five-year mandatory fund is designed with two primary goals: To stabilize vulnerable rural hospitals, health centers, clinics, and their workforces. To improve access, affordability, modernization, and health outcomes for rural residents, who on average experience higher rates of chronic disease, shorter lifespans, and lower earning power compared to urban populations. To help states better understand how to apply and utilize RHTP dollars, ASTHO partnered with Cornerstone Government Affairs to host a discussion on Sept. 4 featuring two expert panels. Participants included representatives from Centers for Medicare & Medicaid Services (CMS) and HRSA, congressional staff, state health departments, and experts from the National Rural Health Association and National Association of Medicaid Directors. Lively discussions provided valuable insights into the application process, how states might deploy funds to build and sustain rural health programs, and the realities of delivering care on the ground. Panel One: Federal Perspectives Application Tips The first order of business was to provide potential applicants with essential information they need to apply. CMS is working quickly to release the Notice of Funding Opportunity in early September. Applications will be due in November, with funding decisions finalized by Dec. 31. This is a one-time application for the five-year mandatory fund, with dollars allocated evenly across FY26 to FY30 ($10 billion per year). Importantly, the RHTP fund is separate from — and unaffected by — FY26 Labor Health and Human Services, and Education discretionary appropriations outlined by the Senate and House, and any continuing resolutions. The $50 billion program will be divided into two parts. $25 billion will be distributed evenly among states that apply and have successful applications. The remaining $25 billion will be allocated at CMS’s discretion based on factors such as a state’s rural population, the number of rural health care facilities, and state policies and policy commitments. States will not be required to provide matching funds. In anticipation of the application deadline, many state health departments have been mobilizing over the past weeks. Health officials are convening task forces, launching working groups and public hearings, and issuing Requests for Information and surveys to shape projects and spending plans. These efforts are focused on aligning with CMS’s strategic goals, including making rural America healthy again, providing sustainable access to care, workforce development, innovative care delivery, and technology modernization. Program Insights Panelists also highlighted how RHTP differs from existing rural health programs. The Federal Office of Rural Health Policy, for example, funds initiatives focused on quality improvement, hospital technical assistance programs for operational challenges, and targeted pilot programs to test the feasibility of ideas related to community needs. By contrast, RHTP will provide states with a large, flexible infusion of funds to augment existing and novel rural health care efforts. States will also be permitted to use RHTP dollars for one-time investments (e.g., electronic health record systems, diagnostic equipment, and network-building initiatives). Panelists emphasized the importance of tailoring approaches to state and community needs, noting that Tribal communities face especially severe challenges, requiring intentional engagement. The first session concluded with a focus on Alaska, where 73.7% of hospitals are in rural areas — a key driver of Senator Murkowski’s strong advocacy for the fund. Her legislative director noted the state’s persistent struggles with connectivity, limited primary care access, workforce shortages, and low patient volume. Previous funding formulas, which relied heavily on hospital bed counts or numbers of health care facilities, often disadvantaged Alaska and similar states. RHTP, structured as a cooperative agreement, gives states both predictability and flexibility: dollars they can count on, combined with broad authority to design solutions in partnership with CMS protocols and assistance. CMS has existing protocols for grant management, and Congress will likely ask for clear reporting requirements as they monitor the successful implementation of the fund. Panel Two: State and Stakeholder Perspectives Rural Health Challenges To align visions with on-the-ground realities, health department leaders from Pennsylvania and Mississippi described their extensive efforts underway to gather input and identify priorities that are both sustainable and impactful, underscoring the importance of community engagement in shaping state strategies. Panelists noted that states are working through a broad list of rural health challenges, including: Maternal and child health. Behavioral health. Substance use disorder. Emergency medical services. Transportation barriers. Aging populations. Specialist shortages. Data modernization (including cybersecurity, AI, broadband, training, and administrative support). Telehealth. Workforce shortages. Hospital, clinic and federally qualified health care center closures. Payment models (public and private). Improving health information exchanges and electronic heath records were also mentioned as universal goals. RHTP is designed with flexibility to tackle these issues and to craft solutions (some of them can be shelf-ready, such as technology or prevention kits) to respond to the diverse needs of rural communities. Aligning Programs Panelists were asked how they are working with partners to achieve alignment for their programs. All concurred that strategic planning is essential, with an emphasis on local partnerships and regional collaborations. It was stressed that rural health care should ideally be delivered as close to the community level as possible, supported by a robust ecosystem. Speakers agreed that the financial health of rural areas is inseparable from the health of their hospitals and clinics. It was underscored that local residents are deeply invested in their communities and want to see them thrive. Transforming rural health care systems will require large-scale collaborations at a local level, which are built on trust, a shared vision, and a clear understanding of the long-term goals. The challenges of chronic disease, which occurs and leads to death at significantly higher rates in rural areas, surfaced. Panelists agreed that tackling this issue requires major investments in ancillary professions — such as nutritionists, physical therapists, and community health workers — alongside a renewed emphasis on primary care services and alleviating the acute shortage of primary care physicians. According to the American Medical Association, roughly 65% of rural areas face a shortage of primary care providers, and only 4%-5% of incoming medical students now come from rural backgrounds. Some solutions noted by the panelists were extending medical student rotations in rural settings from a few weeks to 12 or more, coupled with financial and professional incentives. Encouragingly, research shows that students from rural areas are far more likely to return home as practicing physicians. Final Words Panelists overwhelmingly agreed that RHTP represents an unprecedented opportunity for states — though, notably, not for U.S. territories or Washington, D.C. — to expand access, raise the quality of rural health care, and ultimately improve both quality of life and life expectancy for their rural residents. The $50 billion fund is not only a lifeline but also a testing ground, and if implemented successfully, it could serve as a model to pave the way for future federal investments of this magnitude in rural health. For more information on RHTP, please email MAHARural@cms.hhs.gov. Participants Part One: Federal Senator Lisa Murkowski and Angela Ramponi, MPH, Legislative Director Emily Chen, MBA, Senior Advisor, Office of the Administrator, Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services Tom Morris, MPA, Associate Administrator for Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services Moderated by Carlos Jackson, Principal, Cornerstone Government Affairs Part Two: State and Stakeholder Daniel Edney, MD, FACP, FASAM, State Health Officer, Mississippi State Department of Health Debra Bogen, MD, FAAP, Secretary of Health, Pennsylvania Department of Health Zil Joyce Dixon Romero, State Government Affairs Manager, National Rural Health Association Lindsey Browning, Deputy Executive Director of Programs, National Association of Medicaid Directors Moderated by Susan Kansagra, MD, MBA, Chief Medical Officer, ASTHO article yes

Learn about four Congressional hearings focused on challenges affecting older adults, including inflation and opioids.

State and territorial health officials gathered on Capitol Hill to meet with lawmakers and discuss public health priorities—learn more about Hill Day in this blog post.

Read ASTHO's latest on how appropriations bills and budget cuts could affect the Debt Ceiling and the U.S. economy.

Get vital background on the ACA enhanced premium tax credits and read about 2025/2026 congressional developments for the subsidies.

Learn how the U.S. Government has responded to Long COVID to reduce cases and mitigate the effects, common among women, Hispanic persons, and other groups.

State and territorial health officials share priorities and build relationships on Capitol Hill.

HHS Budget Hearings Chart New Direction for Public Health Budget Hearings Chart New Direction for Public Health Catherine Jones Learn about the key policy/funding themes that emerged from HHS Secretary Robert F. Kennedy’s testimony during the May 2025 budget hearings. In May 2025, HHS Secretary Robert F. Kennedy Jr. appeared before the House and Senate Appropriations Committees as well as the Senate Health, Education, Labor, and Pensions (HELP) Committee to discuss the Trump Administration's proposed FY26 HHS budget. On May 2, President Trump released his “Skinny Budget,” which formed the basis of much of the questioning Sec. Kennedy received from members of both parties. These hearings illuminated a sweeping reorganization of HHS and other federal agencies, signaling a dramatic shift in public health priorities and funding. Seven key themes emerged from the testimony, highlighting how these priorities are being advanced through the Make America Healthy Again (MAHA) initiative and the newly proposed Administration for a Healthy America (AHA). The President’s Budget Appendix, released in late May, reaffirms these policy and funding proposals. Reorganizing HHS and CDC The blueprint for HHS calls for consolidating various agencies under the new AHA, including HRSA, SAMHSA, and parts of CDC. In the hearings, Republicans broadly supported MAHA and AHA initiatives, mentioning the need to disrupt bureaucratic inefficiencies, reduce regulatory hurdles, and improve health care delivery. Democrats expressed concerns about program disruptions, layoffs, and FY25 appropriated funds that remain undisbursed. A handful of Democrats pressed Sec. Kennedy on whether he would spend FY26 funds, as appropriated by Congress; he responded affirmatively. When asked who authorized the staff layoffs, Sec. Kennedy gave inconsistent responses claiming ownership in one hearing and later attributing decisions to the Department of Government Efficiency. Public Health Preparedness and Prevention Preparedness and prevention were central topics, especially in the HELP Committee hearing. The proposed elimination of the Hospital Preparedness Program and cuts to the Public Health Emergency Preparedness Program would result in a net loss of hundreds of millions of dollars in federal support. HELP Committee Chair Sen. Bill Cassidy (R-LA) voiced concerns about the implications for under-resourced and rural states. Sec. Kennedy emphasized CDC’s legal responsibility for national pandemic response and called for reauthorization of the Pandemic and All-Hazards Preparedness Act. In the House hearing, he also addressed topics such as supply chain independence from China for critical medicines, and adequate funding for the Strategic National Stockpile and Biomedical Advanced Research and Development Authority. Vaccines Sec. Kennedy's past vaccine skepticism drew bipartisan scrutiny. Lawmakers pressed him to affirm support for routine immunizations, particularly amid a measles resurgence. When asked about pediatric vaccinations in the House hearing, Sec. Kennedy demurred wanting to refrain from giving medical advice. In the HELP hearing, he confirmed that funding appropriated for vaccines would be used accordingly and stated that vaccine recommendations would continue to be made by CDC’s Advisory Committee on Immunization Practices (ACIP). However, on May 27, he contradicted that assurance by directing CDC to remove COVID-19 as a recommended vaccine for pregnant women and children — reportedly without ACIP input. It should be noted that on June 9, a directive from Sec. Kennedy offered formal notice of the immediate termination of the current 17 ACIP voting board members. Injury and Violence Prevention Substance use, suicide, and overdose prevention were major topics around injury and violence. The FY26 budget proposes transferring CDC’s National Center for Injury Prevention and Control to AHA but still eliminates a majority of its programs. These programs have driven progress on opioid surveillance and community-based interventions, and reduced rates of overdose. When asked about preserving the SAMHSA State Opioid Response Grant, Sec. Kennedy said he supported harm reduction tools such as naloxone and community care programs but needed to review the specific grant. He acknowledged overdose as a public health crisis and stated that HHS will maintain 500 addiction treatment centers nationwide. He mentioned his commitment to addiction programs and the administration’s keen attention on preventing fentanyl from entering the United States. Additional questions were raised about high alcoholism rates on reservations, general funding for Indian Health Services, and elimination of LGBTQ+ services in the suicide prevention hotline; Sec. Kennedy promised to follow up on these topics. Chronic Disease, Cancer, and Food Safety Throughout the hearings, Sec. Kennedy underscored his steadfast commitment to reducing rates of heart disease, diabetes, cancers, Alzheimer’s and dementia, and other chronic conditions. He also wants to focus on the challenges of rural health care and rural hospital closures, as well as improved access to care for vulnerable populations, such as older Americans, veterans, and people with disabilities. In his testimony, Sec. Kennedy repeated his commitment to address nutrition and physical activity and to prioritize healthy eating in the Head Start program. He is working closely with FDA to phase out harmful dyes. FDA has fast-tracked approval for vegetable substitute dyes for the food industry. Sec. Kennedy is also focused on combating ultra-processed foods stating that “nutrition reform will address the root causes of diseases,” such as cancer. CDC’s Center for Chronic Disease Prevention is proposed for elimination in the budget, and the Diabetes Prevention Program Outcome Study is paused. Children’s and Women’s Health Lawmakers from both parties voiced concern over misinformation leading to declining vaccination rates and a growing measles threat. Youth mental health and social media harms were emphasized. Senators also raised bipartisan objections to the proposed elimination of CDC’s Childhood Lead Poisoning Prevention Program, which is being revisited. He expressed interest in researching environmental causes of autism and not solely focusing on genetics. In the House hearing, he acknowledged racial disparities in maternal care. Despite proposed cuts to programs like the National Breast and Cervical Cancer Early Detection Program, Sec. Kennedy voiced support for women’s health research. He also said he supports dental care, though he offered limited assurance on fluoride access. The budget proposes to close CDC’s Division of Oral Health. Tobacco Control In the House hearing, Ranking Member DeLauro (D-CT) criticized the proposed elimination of CDC’s Office on Smoking and Health. Senators in the HELP hearing emphasized tobacco’s status as the leading preventable cause of death and warned that staffing cuts would undermine decades of progress. Sec. Kennedy acknowledged the concerns but said he needed to review the specifics. He was also asked about FDA’s inaction on regulating illicit Chinese-made vapes targeting U.S. youth. While Sec. Kennedy presented the FY26 budget as a framework for streamlining government and cutting costs, critics argued that it undermines core public health capacities. As Congress enters markup season and prepares to negotiate final programs and funding levels, the outcome of this year’s budget debate will have long-term implications for the U.S. public health system. article yes

A brief recap of the 2023 fall legislative session on the Hill, especially as it pertains to public health.

This ASTHO blog discusses the benefits and risks of AI in healthcare and federal legislation, including privacy, bias, and safety concerns.

Federal Discussions on Aging Move Center Stage Catherine Jones Reviewing the latest federal discussions on healthy aging policies. As the November elections approach, aging remains a key topic for the candidates themselves as well as for the capacity and quality of nursing homes, assisted living facilities, and the long-term care workforce, which by all accounts is desperately in need of reserves. Congress, the Biden-Harris administration, and federal agencies are racing to keep up with the growing demands and costs of quality of care, and fully addressing inequities and inequalities. It is vital for public health to advocate for healthy aging over the life course and to be inclusive of older adults in all population health efforts. As of 2020, 56 million—or 16.8% of—U.S. adults were ages 65 or older. By 2060, that number will exceed 94 million and represent nearly 25% of the entire population. The older population is becoming more racially and ethnically diverse. Between 2019 and 2040, the proportion of Hispanic or Latino, Black or African American, American Indian or Alaska Native, and Asian American older adults is expected to increase by 115%; the non-Hispanic white older adults’ group will grow by 29%. The U.S Census Bureau projects that, by 2034, older adults will outnumber children for the first time in U.S. history. Social Security and Medicare expenditures will increase from a combined 9.1% of gross domestic product in 2023 to 11.5% by 2035 because of the larger share of older adults. Recent Congressional Hearings In January, the Senate Special Committee on Aging held a hearing focused on assisted living facilities (ALF) and other aspects of long-term care. There are currently more than one million Americans living in ALFs. Witnesses pointed to exorbitant costs and hidden fees (average annual cost is $54,000), lack of transparency and accountability, negative and harmful experiences for patients and family members (including financial exploitation), workforce shortages, inadequate staff training, and lack of additional or specialized care for people living with dementia and Alzheimer’s. Senators sharply questioned the impacts of private equity takeovers and real estate buying sprees of ALFs, public payments, such as Medicaid waivers, and lack of data being collected to guide reforms. Since federal agencies regulate nursing homes, ALFs receiving federal dollars can arguably be held accountable to federal standards. In March, the Senate Committee on Health, Education, Labor and Pensions held a hearing to examine the Older Americans Act (OAA), which passed in 1965, was last reauthorized in 2020, and needs to be reauthorized by the end of 2024. With 10,000 Americans turning 65 every day over the next 20 years, there was bipartisan agreement that the OAA needs to be fully funded. Research shows that the OAA saves money by reducing emergency department visits, nursing home admissions, and preventing complications from chronic diseases. The committee agreed that older Americans are not getting enough support to age in place, including daily meals, adequate nutrition, physical activity, socialization, medical care, fall prevention, transportation, employment, protection from abuse, and housing. One in four older Americans has an annual income of less than $15,000; a near equal proportion lives in poverty. With 40% of OAA funding going to Meals on Wheels and other nutrition programs, it remains a lifeline for many. In April, the Senate Special Committee on Aging held another hearing to address shortages and improve the long-term care workforce. The vast majority (80%) of long-term care facilities report significant staffing shortages, affecting their ability to provide services, accept new clients, or even remain open. In 2022, the median hourly wage for direct care workers was just above $15. The hearing also highlighted bipartisan solutions to improve pathways to enter the workforce, compensation, and the working environment. Biden-Harris Administration Unveils Workforce Rules Nationally, seven million older adults and people with disabilities rely on home- and community-based services (HCBS) under Medicaid at an annual cost of $125 billion. Approximately 2.8 million workers provide in-home care, and predictions are that the industry will need an additional one million workers by 2030. On April 22, the Biden-Harris administration unveiled The Ensuring Access to Medicaid Services final rule aimed at improving job quality and pay for direct care workers. This CMS ruling (sometimes referred to as 80/20) requires that, in six years, states ensure a minimum of 80% of Medicaid payments for services go toward compensation for direct care workers furnishing these services, as opposed to administrative overhead or profit. The rule calls for more transparency in how facilities pay for HCBS, as well as how they set rates. Boosting the low pay will entice qualified workers and lower turnover; home health agencies warned it could drive them out of business. The Biden-Harris administration also set nationwide minimum staffing ratios for registered nurses and nurse aides for nursing homes. The rule requires nursing homes to have a registered nurse on site 24 hours, seven days a week. Facilities must also ensure registered nurses work a certain number of hours per day based on the number of residents. CMS has phased in the requirements, with limited, temporary exemptions. Experts call the rule a significant step toward bolstering nursing home quality and safety, but again, a understaffed nursing homes forced to hire more workers claim they cannot take on the financial burden. Reframing Aging Summit in Washington, D.C. The Gerontological Society of America’s Reframing Aging Summit kicked off in April with a dynamic discourse on reframing aging through a wider, more inclusive and compassionate lens, poignantly summed up by Kina White, DrPH, MHSA, FACHE, Office Director, Office of Community Health Improvement, Mississippi State Department of Health. “As you take a breath you age. We must normalize age and integrate it across all public health systems. Embed it in all funding. There is no room for ‘othering’ when we’re all aging with every breath,” said White. ASTHO’s government affairs team will continue to track policy and legislation related to healthy aging and share the latest news. website yes

Read coverage of congressional hearings featuring Secretary Robert F. Kennedy, Jr., and his testimonies on the FY27 Budget, including HHS proposed cuts.

Hill Day Advocacy at ASTHO’s 2026 Spring Leadership Forum Hill Day Advocacy at 2026 Spring Leadership Forum Catherine Jones Learn about key topics from Hill Day at ASTHO's 2026 Spring Leadership Forum, including crucial public health funding and access to care. While spring brings many familiar rites of passage, ASTHO’s Spring Leadership Forum stands out as a defining moment each year. For one week, ASTHO Board Members convene with health officials from states and the U.S. territories and freely associated states (FAS) in Washington, D.C., to examine pressing public health policy issues, participate in leadership and policy training, and align cross-jurisdictional priorities. This year’s forum saw a record number of more than 40 health officials. It included discussions with federal agency experts, meetings with congressional offices during Hill Day, and specialized sessions (e.g., Rural Health Academy and public health communications in the AI Era). Federal Agency Meetings ASTHO’s Board of Directors met with leadership from HHS, including representatives from the Office of the Assistant Secretary for Health, CMS, Administration for Strategic Preparedness and Response, SAMHSA, and HRSA. Discussions focused on: Strategic priorities for each agency. How to strengthen federal-state collaboration. Sustaining public health infrastructure. Addressing emerging health priorities. Hill Day Meetings About Public Health Funding ASTHO organized meetings with members of Congress and their staff to highlight the importance of sustained, stable, and robust public health funding — specifically, the Public Health Infrastructure Grant (PHIG) and Rural Health Transformation Program (RHTP). PHIG A central priority was advocating for a $1 billion allocation for PHIG in FY27 to strengthen the public health workforce, data systems, and foundational capabilities health departments rely on. Officials noted the impactful use of PHIG dollars in their states, how this funding directly supports local health departments, and emphasized that public health funding has historically followed a boom-and-bust cycle tied to emergencies — leaving federal agencies and state and local health departments to respond to major crises without consistent infrastructure and workforce support between events. RHTP Conversations also addressed the Rural Health Transformation Program and the challenges of deploying large federal investments quickly and effectively. Participants discussed an innovative pilot that allows Medicare reimbursement for emergency medical services responding to calls that do not result in hospital transport. Additional topics included: Clinical workforce shortages. Measles outbreaks. Vaccine access and insurance coverage. Emergency preparedness (i.e., the Strategic National Stockpile). Adequate lab capacity. Impacts of delays in federal grant funding. Workforce. Broader efforts to redesign health care systems to prioritize prevention and keep patients out of emergency rooms. Hill Day Discussions with U.S. Territories and Freely Associated States Meetings with congressional committees focused on issues facing the U.S. territories and FAS, such as those surrounding Medicaid funding and access to care for veterans. Medicaid Funding Territorial health leaders emphasized the critical role Medicaid plays in sustaining island healthcare systems, where the program serves as a backbone of coverage for many residents. Congressional action has helped stabilize territorial Medicaid funding by establishing a permanent 83 percent Federal Medical Assistance Percentage (FMAP) for the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa, and a temporary 76 percent FMAP for Puerto Rico. However, leaders stressed that Medicaid funding remains vulnerable to statutory caps that are too low and future policy changes. They also emphasized Puerto Rico’s current FMAP will expire in 2027. Access to Care for Veterans Representatives from FAS (the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau) raised concerns about access to health care and mental health services for veterans. While veterans from these nations are eligible for certain benefits through the Department of Veterans Affairs, many must travel long distances to receive care in Guam or U.S. states — creating significant financial and logistical barriers. Leaders emphasized solutions to improve access, including: Expanding telehealth services. Mail-order pharmacy options. Beneficiary travel programs. Leveraging existing on-island hospitals and clinics. Ensuring veterans can receive care and age in place in their home communities supports their health, strengthens local health systems, and reinforces longstanding partnerships between U.S. states and critical Pacific Island allies. Looking Ahead ASTHO extends its sincere appreciation to the members of Congress, congressional staff, committee staff, and federal agency leaders who met with state and island delegations and engaged in thoughtful dialogue on strengthening public health systems. In the months ahead, ASTHO’s Government Affairs team will continue working closely with congressional offices to provide timely data and perspectives, and to advocate for sustained federal investment in public health programs and territorial and FAS health care issues. ASTHO remains committed to advancing solutions to ensure health agencies have the resources and flexibility needed to address today’s public health challenges and prepare for those ahead. Reviewed by - Carolyn Mullen article yes

Lame Duck Session Priorities in Congress 2024 Lame Duck Session Priorities in Congress Catherine Jones With several public health/health care policies set to expire, learn about the must-dos and must-haves that lawmakers have just weeks left to address. The 118th Congress resumed on Nov. 12 and is now facing a tight deadline to address government funding and other pressing legislation before the session ends on Jan. 3, 2025. With several public health and health care policies set to expire, lawmakers have just weeks left to address must-do and nice-to-have items. Only time will tell what gets wrapped up in this lame duck session, and what unfinished bills and appropriations remain on the docket for the 119th Congress. Must-Do Items Disaster Relief Following Hurricanes Helene and Milton, Congress aims to boost FEMA’s disaster relief budget, and Speaker Johnson (R-LA) has prioritized this funding increase. A bipartisan bill led by Jared Moskowitz (D-FL) proposes $10 billion for FEMA and an additional $5 billion for the Department of Housing and Urban Development. Government Funding The current Continuing Appropriations Act (H.R. 4366) expires on Dec. 20. Options moving forward include an omnibus bill(s) or, much more likely, a continuing resolution (CR) extension into March 2025. If there is momentum for an omnibus, Congress might pass the 12 appropriations bills in two bundles as it did in 2023. As a reminder, the Senate's Labor, HHS, Education bill proposes modest increases for CDC and HRSA, with funding lines of $9.34 billion for CDC (an increase of $173 million) and $8.94 million for HRSA. In comparison, the House's version includes significant cuts of $1.8 billion (or 22%) from CDC and $647 million from HRSA. Farm Bill The Farm Bill, governing nutrition programs (SNAP and WIC) and agricultural programs, expired in September 2023. With a new five-year Farm Bill unlikely to pass, Congress will need to figure out a short-term extension through a CR. Nice-to-Have Items In March, the Continuing Appropriations Act (H.R. 4366) extended several expiring health care programs until Dec. 31. Addressing policy issues and extending funding in a new CR will require bipartisan cooperation as lawmakers weigh budgetary concerns with health care and public health needs. Community Health Centers: Reauthorization and continued funding will allow these centers to provide essential primary and preventive care to underserved populations, particularly in low-income and rural communities. Federal funding is needed to maintain operations, staffing, and expanded services. Telehealth: Extending telehealth provisions has broad support, but key issues remain, including: Long-term funding to sustain telehealth infrastructure and reimburse providers. Fraud prevention, particularly around billing, and additional safeguards or restrictions. Scope of services that should qualify for telehealth reimbursement, especially as virtual care becomes integrated into the standard health care delivery model. Hospital-at-Home Program: Popularized during the pandemic to reduce hospital overcrowding and minimize infection risks, this program allows patients to receive acute care in their homes rather than being admitted to hospitals. A two-year renewal is likely, as this model has shown benefits in reducing costs and improving patient comfort; however, long-term sustainability will depend on federal support and reimbursement structures. National Health Service Corps: In an effort to alleviate provider shortages and increase retention in high-need regions, federal funding provides scholarships and loan repayment to health care providers employed in underserved communities. Teaching Health Centers: These centers offer new physicians residency training programs (usually primary care and behavioral health) in community settings to mitigate workforce shortages and improve access to care. Special Diabetes Program: Funding supports ongoing studies and innovations. Medicaid Disproportionate Share Hospitals (DSH): Scheduled cuts to DSH payments were delayed under the current CR, and further delays are necessary to prevent financial strain on DSH serving low-income and uninsured patients. Likely Deferred to the 119th Congress Reauthorization of PAHPA and the SUPPORT Act The Pandemic and All-Hazards Preparedness Act (PAHPA) is essential for strengthening preparedness for public health emergencies. Corresponding legislation, S. 2333, is currently under consideration and faces challenges as lawmakers negotiate the scope and authorize funding levels of the act, to ensure the ability to respond to future health crises. The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act includes provisions for expanding access to treatment, improving recovery services, and funding programs aimed at reducing opioid misuse and overdose. H.R. 4531, currently pending action in the Senate, aims to reauthorize and extend these initiatives. Health Care Policy and Legislation 340B Drug Discount Program: This program requires drug manufacturers to offer discounted prices to health care providers serving uninsured and low-income patients, allowing hospitals and clinics to stretch scarce resources. Potential reforms have been proposed to address concerns over how the savings are used, with some advocating for tighter controls to ensure that 340B benefits go directly toward patient care rather than administrative costs or other expenses. Health Care Transparency and Pharmacy Benefit Manager Reform: Bipartisan (S. 172) efforts are underway to enhance health care price transparency and reform pharmacy benefit manager practices. The House-passed Lower Costs, More Transparency Act (H.R. 5378) includes measures to strengthen price transparency requirements and increase access to lower-cost generic medications. Cybersecurity Standards for Health Care: With increasing cyber threats to health care systems, proposed legislation aims to enhance cybersecurity standards to protect patient data, secure hospital and clinic networks, and safeguard against cyber-attacks that could disrupt health care delivery. Mental Health Parity: Mental health parity laws require health insurers to provide mental health and substance use disorder benefits on par with medical and surgical benefits. Strengthening parity requirements would ensure that individuals receive adequate coverage for mental health services without facing higher co-pays or lower reimbursement rates. Artificial Intelligence (AI) in Health Care: AI is increasingly used in health care for diagnostics, patient monitoring, and administrative tasks. Emerging proposals seek to create a regulatory framework that ensures AI's safe, effective, and ethical use. Key concerns include data privacy, potential biases in AI algorithms, transparency in AI decision-making processes, and integrating AI tools in clinical settings. These proposals may also address accountability for AI-driven decisions and the standardization of AI practices. article yes

Reviewing federal policies to mitigate public health risks of heat exposure.

Assessing the future of the federal Supplemental Nutrition Assistance Program (SNAP).

Strategic federal legislative efforts to stem the U.S. fentanyl crisis.