I’m Keith Sakata, and this is The Signal—a newsletter that cuts through the noise to surface the strongest arguments in healthcare. No fluff. Just steelmanned debates, deep dives, and clear thinking on medicine, policy, and innovation.
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Today's Read: 13 minutes
The Big Issue
The HHS layoffs. Matt Cutler had spent over a decade safeguarding social and nutritional services for the elderly. On Tuesday morning, April 1st, he opened his inbox to find a 5:00 a.m. email informing him he no longer worked for the Administration for Community Living. He wasn't alone—nearly 10,000 employees across the Department of Health and Human Services were being abruptly dismissed in what Robert F. Kennedy Jr. called a “realignment,” but insiders described it as a “purge.”
So What?
This isn’t just reshuffling—it’s a shift in how America tackles public health, biomedical innovation, and trust in its institutions. Whether you see it as reform or sabotage, the outcome could reshape who gets care and how fast the next medical breakthrough reaches your family.
The Big Picture
The cuts were the peak of a sweeping personnel reshuffle by the Trump Administration, starting with the infamous “Fork in the Road” email sent on January 28. The email was followed by the “What did you do last week” email on February 24th. The very next day, the House of Representatives passed a budget blueprint charging the committee that oversees Medicaid with finding $880 billion worth in savings over the next decade—Donald Trump said that Social Security and Medicare were off limits.
Then on March 27th, the HHS announced its restructuring plan for the Make America Healthy Again (MAHA) agenda. “This restructuring is more than just trimming bureaucratic excess. It’s about reshaping the agency to directly tackle the chronic illness crisis in America, ultimately doing far more with less taxpayer money,” Kennedy explained. As part of this overhaul, HHS plans to consolidate 28 existing divisions into 15, create five regional offices instead of ten, and centralize functions like HR, IT, and procurement under a new division—the Administration for a Healthy America. HHS claims the reorganization will improve coordination of services for vulnerable populations and save taxpayers $1.8 billion annually.
The MAHA agenda centers on four policy directives: ending America’s epidemic of chronic illness, restoring trust in public health, empowering patients with transparent data, and integrating food and environmental health into the medical system. The commission’s first priority is investigating why rates of childhood chronic illness have skyrocketed compared to peer nations. Within six months, it promises to deliver a national strategy grounded in “gold-standard” research—independent from pharmaceutical and agricultural lobbying influence. Trump has also pledged to reinstate and expand Executive Order 13877 on healthcare price transparency, as a cornerstone of patient empowerment against hospitals.
The layoffs are the muscle behind the restructuring. By April 1, HHS had executed a 10,000 workforce reduction, on its way to trimming staff from 82,000 to 62,000 employees. The hardest-hit divisions were the CDC and FDA, where entire offices overseeing tobacco regulation, reproductive health, workplace safety, and vaccine development were eliminated or gutted. Top leaders—like Peter Marks, head of the FDA’s Center for Biologics Evaluation and Research (and a key leader for Operation Warp Speed), and Heanne Marrazzo, director of the National Institute of Allergy and Infectious Disease—were either reassigned, placed on leave, or quit outright. Others, like NIH communications staff, were offered abrupt transfers to the Indian Health Service in Alaska with 48 hours notice.
Kennedy has since framed the overhaul as a long-overdue cure to a bloated bureaucracy, and insisted that most front-line roles remain intact. “We had over 100 comms departments, dozens of HR offices—none of them talking to each other,” he said. “Now, every employee will wake up asking how they can help Make America Healthy Again.”
But inside the agencies, the mood is dim. “Humpty Dumpty is shattered,” wrote former FDA Commissioner Robert Califf. “Even if this works out, no one should pretend it was done with care.” On April 3rd, HHS reported that about 2,000, or 20%, of the layoffs were done in error, and will plan to reinstate that workforce.
Today, we’ll explore how both institutional leaders and frontline professionals are responding to the HHS overhaul—from top-down praise to ground-level fallout. Then, my perspective.
The Centralized Point of View
- Critics oppose the cuts, arguing they threaten decades of progress in medical innovation.
- Some contend the cuts reflect a contradictory policy approach by MAHA.
- Others warn the NIH funding reductions could damage America's biomedical leadership.
Former FDA Commissioner, Dr. Scott Gotlieb warned on X that cuts threaten to reverse decades of progress in drug regulation and innovation.
“Twenty-five years ago, it was common to hear complaints about a “drug lag”—the perception that Europeans routinely enjoyed medical advances years before their American counterparts. Through a generation of congressional actions, investments in expertise and hiring, and careful policymaking, we built the FDA into the most efficient, forward-leaning drug regulatory agency in the world—and established the U.S. as the global center of biopharmaceutical innovation,” Dr. Gotlieb said. “Today, the cumulative barrage on that drug-discovery enterprise, threatens to swiftly bring back those frustrating delays for American consumers, particularly affecting rare diseases and areas of significant unmet medical need.”
On Bloomberg, Lisa Jarvis argued that MAHA is contradicting itself.
“We take for granted much of the good work done at agencies like the Centers for Disease Control and Prevention, the Food and Drug Administration and the National Institutes of Health. And that’s how it should be. Those who work in public health like to say that when everything is going right, their work is invisible,” Jarvis wrote. “But we benefit daily from the tens of thousands of people working behind the scenes. We grab food out of the fridge without worrying that it might make our kids sick. We go into the medicine cabinet for our cholesterol medication without wondering if the capsule is contaminated—or if the drug works. When a family member is diagnosed with cancer or a rare disease, we trust that somewhere out there, scientists are working on a cure.”
“Across HHS, the elimination of support staff, including human resources, lawyers, communications teams and lab managers, along with the ongoing depletion of supplies, is paralyzing,” Jarvis said. “Because little information has been shared about the cuts, including the reasoning behind the decisions or even details of who is gone (a situation in direct opposition to Kennedy’s vow of ‘radical transparency’), it will take time to grasp the true scope of the damage. But what’s already clear is that it runs deep and that what’s left cannot be easily cobbled back into a functional health infrastructure.”
On The Free Press, Dr. David Andorsky said the NIH funding cuts are reckless
“Slashing indirect funds is wielding a sledgehammer where a scalpel would be more appropriate. Every academic biomedical scientist I know is worrying about when their grants are going to get reviewed, how they are going to afford to conduct their research, if they can afford to bring on new graduate students, the next generation of researchers-in-training,” Dr. Andorsky said.
“Every dollar the NIH spends on biomedical research is estimated to yield over $2.46 in economic activity. Most of the new classes of drugs I use to treat my patients had their origin in basic research funded by the NIH,” he wrote. “Scientists come from around the world to study in American labs—do we really want tomorrow’s American scientists to have to go to China to work in the world’s best labs? The American biomedical research establishment is the envy of the world. If we want to put “America first,” I don’t see why the Trump administration wants to jeopardize all of that to save what, in the end, is a small amount of money in the scope of the federal budget.”
“The only way to understand the Trump administration’s actions here, in my view, is either as a concerted effort to destroy federal funding of biomedical research, or to place such a high value on rooting out all traces of “wokeism” or “gender ideology” from biomedical research that it is willing to bring the entire operation to a halt in the service of its own ideological agenda.”
The Decentralized Point of View
- Supporters argue Kennedy could positively disrupt the status quo of American public health.
- Some emphasize the need to mend public trust with intellectual diversity.
- Others call for restructuring the NIH to better serve public interests.
In The Wall Street Journal, Menachem Spiegel suggested Kennedy’s approach could beneficially disrupt American healthcare.
"Mr. Kennedy will radically reshape the landscape of public health in America, and that isn’t necessarily a bad thing. His presence in the field will mean that there is a counterweight to the pharmaceutical and food industries’ disproportionate influence, and his contrarian ideas can help challenge a scientific community that has taken on the appearance of an echo chamber rather than a hub of critical thinking,” Spiegel said. While some of his previous statements range from outlandish to outright conspiracy, he has walked back many of those controversial views, stating that he is supportive of vaccines and would work closely with Sen. Bill Cassidy—a physician and chairman of the Senate Health, Education, Labor and Pensions Committee—to enact reforms.”
“American health is in dire need of reform. Something must change. A 2023 Gallup poll found that only a third of Americans have faith in the medical system. More than 40% of American adults are obese. Diabetes affects more than 30 million Americans. The numbers are staggering and getting worse,” he wrote. “Business as usual isn’t working. Every town needs a crazy person to call out society’s flaws when everyone else is afraid to speak up. Perhaps Mr. Kennedy can be that for America, shaking up our health system and improving lives.”
On Substack, Dr. Vinay Prasad argued that media criticism of funding cuts misses the point
“Every time Trump cuts something, the media screams. How can you cut funding on <this important issue>?, they ask. The media tries to define the debate as ‘is this an important topic’? But that isn’t the right question. The question is ‘will these funds make a positive impact on the topic?’ Dr. Prasad asked. “We all know in medicine there are different doctors and scientists. There are a few who are open minded and curious, who approach issues from all vantages. They are willing to consider that the recent rise in vaccine hesitancy is fueled by third party fringe elements, but also willing to consider it was fueled by the misguided covid-19 vaccine campaign and mandate, and the annual booster campaign.”
Then there are the ideologues. Vaccine researchers who just repeat bland slogans “they are all safe and effective!” without considering nuance. Ideologues invariably blame third parties— and ignore all the recent errors. Many of the people with grant funding to study this topic are ideologues,” Dr. Prasad asserted. “We need new ideas and innovative approaches to vaccine hesitancy. We need researchers who are at least willing to consider that one reason it is rising lately is that our covid policy further bred distrust. How can you overcome that if you won’t admit it? The media keeps whining about what Trump cuts, but their analyses are superficial. I think they are unhelpful. Take a look at the specific grants, you will find many should be cut. Very often you will find that a field needs a reboot.”
On The Free Press, Dr. Joseph Marine advocated for structural reforms and increased responsiveness at the NIH.
“I am a cardiologist at Johns Hopkins Medicine who has a longtime interest in health policy. During Covid, I watched in alarm as Dr. Bhattacharya was maligned and sidelined for raising necessary and thoughtful objections to draconian Covid policies, such as lockdowns and school closings. Both these policies and the attacks on Dr. Bhattacharya were promoted by top NIH officials,” Dr. Marine wrote. “So it is indeed “poetic justice” that he is now going to be in charge. Dr. Bhattacharya has said his mandate is to bring change to the NIH.”
“The NIH began in 1887 as a one-room laboratory. It is now 27 separate institutes, each in its own bureaucratic silo. In academic medicine today, divisions and departments are being reshaped to consolidate research based on a more modern understanding of the interactions of disease processes. A similar reorganization of the NIH’s structure is overdue,” he said. “The NIH, which was established as a public health agency, should be more responsive to the American people. During the pandemic, their leadership exhibited a sense of entitlement, grandiosity, and self-importance that is unhealthy for the NIH and anathema to good medicine and science. A fresh perspective is sorely needed to address the roots of the U.S. chronic disease epidemic and restore public trust in our federal health agencies.”
How I See It
"How I See It" is where I share my perspective. Got feedback or criticism? I’d love to hear it—just reply to this email or drop a comment.
- The budget argument doesn’t hold water.
- Gutting FDA staff and calling it “efficiency” misses the mark.
- Fixing public trust post-COVID is essential—but execution matters, and this rollout risks doing more harm than good.
I am unconvinced by a few arguments for the HHS cuts.
To me, when the HHS Secretary, Robert F. Kennedy Jr., says that he wants to cut a quarter of his department in order to save $1.8 billion, I scratch my head. I agree that the size of the national debt is unacceptable, growing, and needs to be corrected. But the cuts amount to 0.1% of the entire HHS budget or $5.29 per U.S. adult (assuming those savings get returned to all 340 million Americans, which they don’t).
Another unconvincing argument is that cuts are a step in the right direction towards improving long-term efficiency of the HHS. The assumption is that on paper, fewer people leads to greater efficiency. If you fire enough people, the gears in the system start to breathe.
This is a fallacy. If the goal is to get innovative ideas and products out to market, faster and safer, a viable strategy would be to increase the number of people that are enabling a higher capacity of FDA approvals. Perhaps the biggest positive externality is predictability from the agency, which means that innovators and investors can move much more quickly (with the right data of course). As I’ve said before, if more medicines like GLP-1s hit the market, they are saving more lives and potentially saving healthcare costs at a larger scale.
$5.29 per capita for faster innovation approval does not seem like a bad trade.
If Kennedy’s team was actually consolidating redundant positions, I might be convinced. But the HHS reportedly let go of a chunk of workforce related to drug approvals, tobacco oversight, and procurement (i.e. how scientists get their materials). In fact, the FDA was hit the hardest and lost 19% of its workforce. Take it from Dr. Robert Califf, the previous FDA commissioner, who said “The FDA as we've known it is finished, with most of the leaders with institutional knowledge and a deep understanding of product development and safety no longer employed.”
Perhaps the biggest sin of all was the execution. Although potentially biased, there are tons of reports of top-down communication that was fragmented to nonexistent. If you are trying to rally your post-cut team to do hard things, this is not the way. In the short-term you sink morale and trust. In the long-term, you invite a brain drain and a loss of institutional knowledge.
To be clear, I’m not entirely opposed to the MAHA agenda—which to me, resembles a horseshoe-theory style union between typical conservative concerns about purity and typical liberal concerns about the environment. And I don’t think that RFK is the boogeyman the media paints him out to be.
I find myself of two minds when it comes to his views. When I hear him speak about regulatory capture or the cozy relationship between big pharma and the government, or the elitism and censorship by our gatekeepers, I find myself nodding along. But one of the most dangerous things about RFK is there are bits of things he says that are off-target, and they’re mixed in. So when I hear him insisting that vaccines are unsafe and are the reason for autism, or that antidepressants are poisons, he loses me.
To me, I think the best way to shine light on Kennedy’s cuts is to look at the more compelling reason for them—that this is all about correcting a system responsible for COVID-19 wrongs.
Regardless of your thoughts of how we responded to the epidemic, it’s clear that the public thinks that we fumbled. Badly. Our public officials failed on multiple fronts—1.2 million Americans died of or with COVID, our children were deprived of education and mental wellbeing, and the CDC botched the production of testing kits. Perhaps the biggest failure of all was the utter breakdown of public communications and trust, starting with the CDC red-light, green-light on masking.
In a lot of ways, we will feel the consequences of this for a long time. The data shows that there is a perception that elites are imposing their value system on the rest of society. A recent Gallup poll showed that of 23 professions, physicians had the largest drop in public trust levels from 67% in 2021 to 53% in 2024. A JAMA study replicated that trust of physicians and hospitals decreased from 71.5% in 2020 to 40.1% in 2024. Consider that only 14% of people with low levels of trust take their medications. Americans think that we need to be better at presenting ourselves as deserving and worthy of their trust.
And I don’t blame them because there is a lot of room for improvement. In 2023, a report from the Government Accountability Office (GAO) did find “persistent deficiencies in HHS performance” like a lack of clear roles, inconsistent data, unclear communication, and a deficit of “transparency and accountability.” During the same year, the US Office of Special Counsel determined that HHS had misappropriated millions of dollars (around $25 million) that were supposed to fund vaccine research and emergency preparedness.
As a former NIH fellow, I’m familiar with the incentive to spend down your budget to avoid cuts the following year. The funniest purchase I've seen is 30 pounds of napkins.
So when looking at the whole, I see that health outcomes in the U.S. are unacceptable relative to the amount of money that we spend. This spending is driven by two levers: utilization (the number of services used) and price (the amount charged per service). And despite spending nearly twice as much on healthcare than other countries, utilization rates do not differ from other wealthy OECD countries. Prices therefore, appear to be the main driver of cost difference—and something that the Trump Administration seems eager to fix.
But even if I think the MAHA agenda has the right idea—I cannot stress how important execution is to having the right impact. Running a DOGE playbook at HHS seems at least hurtful and at most dangerous.
Don’t see it the same way? That’s fair—this is just one perspective. Share your thoughts by replying to this email or commenting, and we might feature your response.
By The Numbers
- $1.8 billion — The projected annual savings from cutting 25% of the HHS workforce, or just 0.1% of its $1.7 trillion budget.
- 547% — The inflation-adjusted increase in HHS spending since 1980, outpacing the federal budget's overall growth rate of 194%.
- $24.13 billion — The estimated total value of HHS grants terminated in early 2025, including over $12 billion from state public health and DEI-related NIH programs.
- $2.46 — The estimated economic return for every $1 NIH spends on biomedical research, according to United for Medical Research.
- 3,500 / 2,400 / 1,200 — Projected layoffs at the FDA, CDC, and NIH respectively. FDA's cut represents 19% of its workforce.
- 53% — Percentage of Americans who said they trust doctors in 2024, down from 67% in 2021—the steepest drop among all professions tracked by Gallup.
- $12,742 — U.S. healthcare spending per person in 2022, nearly double the OECD average, with no corresponding increase in utilization.
- 0 — The number of NIH grants HHS will prioritize on vaccine hesitancy, DEI, or transgender health under new policies directing focus to “gold-standard science.”