Trump Administration’s HHS Cuts: Creating Waste And Inefficiency, Not Eliminating Them

Published: April 21, 2025

Written by: Sherry Glied and Richard G. Frank

Editor’s Note

This article is the latest in the Health Affairs Forefront featured topic, “Health Policy at a Crossroads,” produced with the support of the Commonwealth Fund. Articles in this topic offer timely analysis of regulatory, legislative, and judicial developments in health policy under the Trump-Vance Administration and the 119th Congress. Please note that an earlier version of this article incorrectly stated that the one person that calculated the Medicaid Federal Matching rate was fired. That was incorrect: One of the two people involved in that calculation retired, while the other is still employed at the Department of Health and Human Services.

At the end of March 2025, six weeks after his confirmation as Secretary of Health and Human Services (HHS), Robert F. Kennedy Jr. sent notices to some 10,000 Departmental employees across HHS immediately terminating their employment. These reductions-in-force followed the earlier retirements and resignations of about 10,000 HHS employees—prompted in part by the government’s offer of Fork-in-the Road—and the still-earlier termination of probationary employees.

All told, these reductions in force have shrunk the HHS staff from about 82,000 (the approximate size of the HHS staff since the end of the George W. Bush administration) to about 62,000, a reduction of nearly one-fourth. The final set of staff reductions were accompanied by a document sketching the concept of a plan to reorganize the Department, consolidating divisions from 28 to 15, centralizing many functions, and eliminating multiple programs.

Many of the staffing and programmatic reductions at HHS and across the government have centered on stated priorities of the new Administration. One may question the wisdom and public health benefits of reducing staffing around diversity, equity, and inclusion; the health of transgender people; or infectious disease control, but their appearance on the government’s hit list is hardly surprising. The biggest changes at HHS, however, are intended to reduce waste and inefficiency, explicitly as a response to President Trump’s February 11, 2025 Executive Order creating the Department of Government Efficiency (DOGE).

A Departure From Prior Efforts To Reinvent Government

Most new administrations arrive in DC with the intention of setting new priorities, eliminating low-value activities, and making government more efficient. Since the early 1900s, there have been over 15 such efforts. In 1978, President Jimmy Carter promised that “civil service reform and reorganization would be the centerpiece of (his) efforts to bring efficiency and accountability to the Federal Government.” President Ronald Reagan in 1982 convened the Grace Commission, a group of private sector leaders, and called for it to “work like tireless bloodhounds. Don’t leave any stone unturned in your search to root out inefficiency.” President Bill Clinton’s National Partnership for Reinventing Government cut some 426,000 jobs from the federal workforce during his Presidency.

But the current Trump administration initiative differs dramatically from its predecessors. Prior efforts to reduce the size and improve the efficiency of government were predicated on the need for an effective government. To that end, they typically began with extensive study through commissions or high-level workgroups that carefully evaluated programs, reviewed personnel allocations and necessary functions, and considered efficient provision of public services. This latest effort is not that. There has been no visible effort to assess how to improve the efficiency of programs: not before the election (Roger Severino’s chapter on Health and Human Services in the Heritage Foundation’s Project 2025, the closest thing to a policy agenda for a second Trump administration, focuses only on eliminating programs that promote abortion and woke policies); not in any public transition documents; and not in the short period since the Administration has taken office.

The current weakly reasoned reorganization, accompanied by the offhand and contemptuous demolition of much of the workforce of HHS, is as logical as taking three different jigsaw puzzles, throwing out two-thirds of the pieces in each one, and trying to reconstruct the remaining pieces into a new puzzle. In combination, these efforts are likely not only to reduce the ability of HHS to improve the well-being of Americans but to work directly against the Administration’s stated goals of increasing the efficiency and effectiveness of the Department.

Undercutting The Trump Administration’s Own Goals

Take, for example, the DOGE’s goal of reducing waste, fraud and abuse in public programs. Doing that requires inspectors, investigators, and administrators focused on maintaining quality, investigating unauthorized enrollments in public programs, and conducting financial oversight. It’s entirely inconsistent with firing the HHS Inspector General and cutting 200 staff in the CMS office of program operation and local engagement who were charged with guarding against fraud in Obamacare Marketplaces.

Or consider the Secretary’s goal of reducing drug prices and combatting “big pharma.” That doesn’t seem consistent with firing Food and Drug Administration (FDA) facility inspectors and the staff in the policy division of the FDA Office of Generic Drugs, the office that develops industry guidance and approves new products. Slower introductions of generics will reduce drug competition and keep prices high. Reduced inspections of foreign producers of active pharmaceutical ingredients will mean that generic drugs, those most frequently dispensed in the U.S., are less safe—and less acceptable as alternatives to the high-cost drugs produced under patent.

Or take the Secretary’s goal of making America healthy again by ensuring that program priorities of operating divisions such as the Centers for Medicare and Medicaid Services (CMS) and the FDA are consistent with those of HHS and the president. That requires having a policy staff that understands what the programs do and how well they do it. That’s inconsistent with firing two-thirds of the staff of the Assistant Secretary for Planning and Evaluation (ASPE), the unit of HHS that houses these capabilities. Indeed, the failure to make use of that resource became evident immediately as reporters challenged the Secretary about the disconnect between Secretarial priorities—addressing diabetes, improving mental health, reducing toxin exposures—and the announced program cuts. As the Secretary himself noted, “Studies that should not have been cut were cut … Personnel that should not have been cut were cut … and that was always the plan.” These were completely self-inflicted errors. The Secretary had tools already at his disposal to help him reduce staffing and improve efficiency while promoting his own policy priorities. Instead, he fired them.

Why ‘Move Fast And Break Things’ Works In Tech But Not In Government

The DOGE approach to improving efficiency at HHS has its roots in the tech industry, where the mantra is to “move fast and break things.” In the tech world, a world of many competing firms that hire similar experts from a broad, global pool (there are nearly 500,000 software developers in Silicon Valley alone), the cost of making personnel mistakes is relatively low. That’s not true in the Federal government. Most units in HHS do not, themselves, execute on health priorities. Particularly since the reinventing government effort of the 1990s, the Federal government accomplishes its goals by contracting with, funding, or advising contractors, states, localities, and organizations who deliver services, field surveys, and conduct analyses. That’s how the childhood lead prevention office at CDC, with just 25 staff, was able to supervise some 3 million blood lead tests each year—before it was, apparently inadvertently, cut in the mass firings.

This structure means that there is remarkably little duplication of effort at HHS. Just one person—now fired—in ASPE computed the national poverty guidelines. Staff who write contracts directing others to do critical work need an extraordinary depth of substantive, analytic, and managerial knowledge. In effect, they are responsible for ensuring the execution of complex and costly governmental programs with immediate and important consequences for millions of Americans; they must meet that obligation at one or two removes from the actual work itself. There is no pool of similarly skilled workers at any other enterprise to replace them with if you fire them first and ask questions later.

Secretary Kennedy’s personnel reductions and planned reorganization of HHS already threaten Americans’ health, as critical programs that respond to specific needs have been cut. But the long-term consequences go well beyond those of shuttering individual programs that respond to specific needs. Kennedy has taken a sledgehammer to the Department’s broader capacity to analyze, track, and improve its own programs and the health system more generally. Rather than reinvent government to better serve the American people, as his predecessors sought to do, he has made government less efficient and effective.