By Rose Hoban
At 10 a.m. today, when a Senate committee is scheduled to begin the first confirmation hearing for Robert F Kennedy Jr., the president’s choice to take charge of the country’s health and well-being, many in North Carolina’s health care and public health communities will be paying close attention to what the nominee and the senators grilling him say.
Even before Inauguration Day, people in these communities were concerned about the possible direction President Donald Trump and his administration could take on health care issues — especially after the nomination of Kennedy to lead the federal Department of Health and Human Services.
Then when the action started in earnest last week, as Trump put his pen into overdrive on his first day in office signing executive orders, some of those people say their worst fears were realized. The presidential directives have paused work at federal health research agencies, ordered employees from the Centers for Disease Control and Prevention to stop working with the World Health Organization and attempted to block the flow of federal grants and loans.
These moves have ground work across many areas of the nation’s health sciences to a halt and jeopardized funding for hospitals, clinics and doctors.
The orders, some of which are already being challenged in the courts, have profoundly rattled many scientists.
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Beth Moracco, head of the University of North Carolina at Chapel Hill Faculty Council, said at that body’s meeting Friday, Jan 24, that she’d been barraged by emails and texts that included the words, “‘tsunami,’ ‘fire hose,’ ‘whirlwind’ to describe the volume and pace with which we’re hearing about not only executive orders, but policies and actions and new regulations, et cetera.”
She recounted sitting in a campus coffee shop last week and overhearing one graduate student say to another, “I just texted my [principal investigator] to see if I still have a job.”
And while the purpose and the pace of the orders may be intended as much to cause panic and disruption as to realign scientific and health care endeavors to the new president’s priorities, many health and public health people wonder what type of system they will be left with when the flurry of activity finally slows.
Reaction on the ground
“I do think that some of the reviews, of course, are welcome. We should always look to be more efficient,” David Wohl, UNC Chapel Hill infectious disease physician and researcher, told NC Health News. “However, is it necessary to stop the flow of funding abruptly for so many different programs, including those that not only are looking to answer questions, but life saving programs?”
Wohl said that some might welcome the shock to the system that Trump’s actions have produced, but at some point, when those shocks start to undermine the delivery of life-saving research, attitudes could shift.
“The complete shutting down of programs that do help many people, that do generate the kind of answers and advances that Americans count on, I think that would be something that many would be surprised about,” he said. ”It’s not, I don’t think, what many people who voted for Donald Trump were really expecting.”
In the short run, though, experts and researchers said they were wondering how to proceed with their work.
Dorothy Cilenti, a professor in maternal and child health at the Gillings School of Global Public Health, said she’d been preparing a lecture last week and went looking for a White House plan to address maternal mortality disparities between Black and white women.
But the document had been removed from the White House website.
“I’m curious what will take its place,” she said. “It was a guide that really helped to identify ways that we could address preventable maternal deaths in this country, particularly for people of color and marginalized communities.
“It was a good plan.”
Cilenti said she understood that Trump wanted to put his philosophical stamp on the government, but she wondered how the drive to remove language about diversity, equity and inclusion from federal documents would affect research on the differences in health that exist among different racial and ethnic groups.
“I mean, how do you do public health without talking about health inequities?” she asked.
‘Watching and waiting’
“The vibe [in Washington] is ‘buckle up, here we go.’ It’ll be an interesting four years,” said Matt Salo, a lobbyist and former head of the National Association of Medicaid Directors.
Though people working at the state level have been rattled, Salo said he was more sanguine about what will happen in Washington, where the 119th Congress is just getting going.
“There’s a broad sense that elections have consequences and the ability of a new administration to put its policy imprimatur on these programs is normal and expected,” he said, noting that the panic level is much lower in Washington. “It could be ‘familiarity breeds complacency.’”
For instance, Medicaid, Salo’s area of expertise, has been in the sights for many Republicans intent on cutting the budget. Salo said there would definitely be changes to the program, but he said he was doubtful that Capitol Hill would be able to make large, sweeping cuts — in no small part because of razor-thin margins in the U.S. House of Representatives.
“I had lunch the other day with a fairly formerly high-ranking Republican staffer who’d been out in the private sector, and they were dismissive of the success of efforts to undermine the program,” he said. “You don’t need to flip more than two Republicans and get a different result.”
Salo also said that the rapid expansion of Medicaid coverage during the pandemic had given many constituents a different view of the program.
“Personally, I think there was a little bit of a sea change,” Salo said. “The Venn diagram of people who had a revelation of what Medicaid was and who were Trump voters had a large overlap. ‘Those people’ doesn’t ring as true now. Now it’s more like, ‘Medicaid is where grandma gets her nursing home coverage and my kid gets his opioid treatments.’
“It’s not as easy to dismiss the program.”
The popularity of the Medicaid program was exemplified on Tuesday, after governors heard from Trump administration officials that the program’s payments would cease for one, perhaps two weeks. Meanwhile, the payment portal connecting the program’s money to states shut down, preventing the flow of Medicaid dollars and the Supplemental Nutrition Assistance Program, known colloquially as “food stamps,” along with the other federal grants.
“The blowback [from state governors] was so strong and so significant that they were forced to do a 180, immediately reverse course and put out a hastily written FAQ clarifying that ‘No, no, no, Medicaid and SNAP are exempt,’” Salo said on Tuesday afternoon.
In North Carolina, health care advocates are taking a cautious watch-and-wait attitude, especially about Medicaid. At the same time, they’re lining up their forces.
“It’ll be a fight, and all our national partners are lining up to play defense to protect the Affordable Care Act,” said Peg O’Connell, a longtime lobbyist for public health issues at the North Carolina General Assembly. “If something does happen, we’ll dust ourselves off and do everything we can to defend our Medicaid program.”
Mark Moss, the division director of public health dentistry at the East Carolina University department of foundational sciences, told NC Health News on Tuesday that while he has concerns about all the directives coming from the new administration, he tries to put it in historical perspective and stick to the principles that have always guided his work.
“These things are cyclical,” Moss said. “We’re a democracy.”
“When Ronald Reagan became president, there was a lot of concern,” Moss added, while acknowledging the concerns about this administration are even more heightened.
‘Channel that anger’
Even with the steady stream of executive orders and directives from cabinet-level agencies, some are already looking ahead to what opportunities they can find to advance their priorities.
“I was angry after the election but felt like I wanted to channel that anger. So, I’m focusing on being more mindful,” said one former state level leader who now works at the national level. He asked for anonymity to not jeopardize the programs he works for. “Instead, I’ve been trying to do a lot of mentoring and listening and talking.”
He also said that public health people have to stand by the science and the evidence.
“If we hang together, we’ll get through this. We really don’t have a lot of choice,” he said. “If you start cozying up to the pseudo-science stuff, you’re gaslighting the profession, and then no one knows what to trust.”
But there’s a lot of work for public health people to do to regain the public’s trust. This week, health policy and research organization KFF released polling data showing a stark partisan divide in who trusts science and scientists.
“Less than half the public overall trust President Trump (42%) and Kennedy (43%) to make the right recommendations on health issues,” a release from KFF read. “Among Republicans, however, similar shares say they trust President Trump (84%) and Kennedy (81%) as say they trust their own doctors (84%).”
And a quarter of Republican parents said they had delayed or skipped some vaccinations for their children at some point.
“We have to advocate for there to be a science-driven agenda that’s based on facts and reality,” said Wohl, the UNC Chapel Hill infectious disease specialist. “I think that’s why RFK Jr.’s nomination has caused so much concern, because of the statements and positions that he’s made.’”
Wohl was optimistic that the evidence would win out. He said he saw that earlier in his career when some people doubted that the human immunodeficiency virus caused AIDS. Much of that resistance faded over time in the face of reality.
“The good news is, facts are facts, evidence is evidence,” Wohl said.
But he acknowledged that it could take time and, likely, casualties.
“People in this country, you know, they bought this messaging, they bought this administration. ‘You buy it, you break it, you own it.’ So let’s just see what happens.
Steve Cline, vice president of the North Carolina Oral Health Collaborative who had been fielding calls for much of Tuesday about what to make of the pause on federal funding, had a similar message.
Trump, he said, “throws out 100 crazy ideas and we get 10 of them that stick.” Too often, Cline added, a sigh of relief follows because 90 of those ideas didn’t materialize into new policies or directions for the country. Now, though, he has great trepidation.
“For me personally, I want to stop saying ‘it’s just Trump being Trump,’” Cline said. “That’s what people used to say. But it feels like all these Republicans are going along with it. This is a whole administration now, and they’ve got to be accountable for it.”
“Some of the extreme policies, we can look to history to see how those have been ultimately bad decisions,” Cline added. “There’s some pretty ugly history.”
Moss, the oral health researcher at East Carolina, acknowledged that this administration has heightened his concerns even more. For decades, the oral health professional has focused on public health equity, and he said he would continue to do that — even if it meant bucking the system.
“I try to focus on the things that are important to me — kind of the principles that matter,” Moss said.
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