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government accountability office
Trump’s Budget Cuts Will Only Make Things Worse for Struggling Rural Hospitals
The budget bill will put enormous strain on rural hospitals, which are often the largest local employer in addition to crucial care providers.
Sep 14, 2025
Bari Senecal waits outside the emergency department at Columbia Memorial Hospital in Hudson, New York. “I do construction. I fell three stories,” Senecal explains. “I was on top of the scaffold and this new kid we hired didn’t put the braces on correctly.”
Like 70 million Americans, Senecal qualifies for Medicaid, the state and federally-funded public health insurance program for low-income patients. She also qualifies for Medicare. She’s what’s known as being “dual-eligible.”
At Columbia Memorial, 63% of patient service revenue is reimbursed through a combination of the two programs. But “we run a deficit every year,” says Dorothy Urschel, CEO of Columbia Memorial Health. “For many, many years, we’ve been reimbursed at well below cost.”
The hospital has the only emergency room serving the more than 110,000 residents scattered among two predominately rural counties. “Of course, we’re struggling,” says Urschel. “But rural community hospitals always struggle.”
Columbia Memorial already closed its maternity ward in 2020—part of a distressingly common trend. A recent study from the Journal of the American Medical Association found that more than half of rural counties now have no hospital-based obstetric services whatsoever.
Like other rural hospitals across the country, Columbia Memorial is bracing for the loss of Medicaid-covered patients and funding because of the Republican reconciliation bill, dubbed the “One Big Beautiful Bill Act,” which was signed by US President Donald Trump this summer.
Over the last decade more than 100 rural hospitals have closed across the country—50 of them in just the last eight years.
According to the nonpartisan Congressional Budget Office, the bill will cut $911 billion in federal Medicaid spending over the next decade and result in an estimated 10.3 million people losing their Medicaid health insurance. Add in cuts to the Affordable Care Act and the number of people expected to lose their insurance rises to 16 million.
According to Larry Levitt, vice president for health policy at the Kaiser Family Foundation, this amounts to “the biggest rollback in federal support for health coverage ever.” And it will put enormous strain on rural hospitals especially—which in Columbia County and elsewhere are often the largest local employer in addition to crucial care providers.
The GOP staggered these cuts so that the worst effects of the budget changes won’t be felt until after the midterm elections in 2026 are safely past. But “some rural hospitals around the country have already started closing” in anticipation of the cuts, warns Michael Chameides, a member of the Columbia County Board of Supervisors.
Senator Ed Markey (D-Mass.) provided a list of 338 rural hospitals in danger of either closing or drastically scaling back services. All 338 had experienced three consecutive years of negative total profit margins and were in the top 10% of institutions with patients on Medicaid.
Rural hospitals facing disaster are identified individually according to which state will see the losses. Kentucky, Louisiana, and California top the list with 35, 33, and 28 rural hospitals identified as at risk of closure, respectively. New York has 11. (Columbia Memorial isn’t officially one of them, but Garnet Medical Health Center Catskills, another Hudson Valley hospital, is.)
An estimated 1,796 hospitals remain in rural America, but those numbers obscure the level at which the services they offer may have already contracted. According to the Government Accountability Office, over the last decade more than 100 rural hospitals have closed across the country—50 of them in just the last eight years.
In New York and every other state, as federal funding runs dry it will be up to the governor and legislature to make provisions for struggling rural hospitals—or stand by and watch them collapse.
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Nonpartisan Watchdog Agency Finds Trump Admin Illegally Withheld Head Start Funds
"The Trump administration broke the law and denied communities the funding they need to create jobs, grow their economies, and support working families," said one Democratic lawmaker.
Jul 23, 2025
The Trump administration has violated at least two federal laws by withholding close to $1 billion from Head Start, the program that provides preschool education to low-income families, a nonpartisan watchdog agency found on Wednesday.
The Government Accountability Office (GAO) determined that the U.S. Health and Human Services Department (HHS) illegally impounded crucial funds from Head Start between January 20 and April 15 of this year, when it distributed only 65% of the money it had provided to the early childhood education program over the same period in 2024.
Head Start lost more than $825 million over that time period, forcing some centers to close.
The GAO found that withholding the funds violated the Head Start Act and the Impoundment Control Act (ICA), which restricts the president's ability to rescind or delay funding that has already been appropriated by Congress.
"HHS has not provided the information we requested regarding factual information and its legal views concerning the potential impoundment of appropriated funds," said the GAO. "Yet publicly available evidence, including data recorded by HHS on its Tracking Accountability in Government Grants System, indicates that between January 20, 2025, and April 15, 2025, HHS withheld from disbursement funds appropriated for Head Start. Based on this evidence, we conclude that HHS violated the ICA."
The office added in its decision that "the Constitution grants the president no unilateral authority to withhold funds from obligation... If the administration wishes to make changes to the appropriation provided for Head Start, it must propose legislation for consideration by Congress."
Previously, the GAO has advised Congress that the Trump administration illegally withheld funds for an electric vehicle charging system and for the Institute of Museum and Library Services.
"Today's legal opinion from the nonpartisan GAO reaffirms a simple truth: The power of the purse belongs to Congress, not the president," said U.S. Rep. Brendan Boyle (D-Pa.), ranking member of the House Budget Committee. "By blocking these investments, the Trump administration broke the law and denied communities the funding they need to create jobs, grow their economies, and support working families."
"Instead of trying to destroy preschool programs and breaking our laws to hurt working families, President Trump needs to ensure every penny of these funds get out in a timely, consistent way moving forward."
The administration has proposed entirely eliminating Head Start, which provides education to more than 750,000 children. Earlier this month it announced that children who are undocumented immigrants will no longer be accepted into the program—prompting a lawsuit that was filed this week by 21 Democratic state attorneys general.
Sen. Patty Murray (D-Wash.), who serves as vice chair of the Senate Appropriations Committee, condemned President Donald Trump for "stealing money from preschool programs."
"No president in modern history has demonstrated such contempt for working and low-income American families as Donald Trump," said Murray, noting that a Head Start program in her state's Lower Yakima Valley was among those that had to temporarily close earlier this year, impacting more than 400 children and more than 70 staffers.
"Today, a top government watchdog confirmed what we've known for months: President Trump has illegally held up vast sums of funding for Head Start programs across America—blocking funding that working families count on every day for pre-K and so many critical services Head Start offers," said Murray.
"Trump has signaled he would like to eliminate Head Start—but that's not his choice to make," she added. "Congress delivered this funding for Head Start on a bipartisan basis, and instead of trying to destroy preschool programs and breaking our laws to hurt working families, President Trump needs to ensure every penny of these funds get out in a timely, consistent way moving forward—and he must also finally get out the rest of the investments he has been robbing the American people of."
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Rebalancing Checks and Balances: How to Curb Executive Abuse
President Trump has conclusively demonstrated that the executive branch cannot be trusted to police itself in following the law. Congress must act to prevent future overreach.
Apr 25, 2025
In his second term, U.S. President Donald Trump has moved aggressively to expand the authority of the executive branch, thereby upending our traditional system of checks and balances among the three branches of government. Reforming this system while he still holds office will be impossible, but he will eventually move on, and Congress should be planning now for changes to the system of shared governance to limit outsize executive authority and prevent future autocratic abuses.
Although President Trump has pushed the envelope further than most could have imagined possible, his abuse of power is reminiscent of the Nixon administration. After the Watergate scandal and the resignation of President Richard Nixon, Congress took steps, such as the Anti-Impoundment Act, to curb presidential excesses. Following the second Trump administration, an even more fundamental restructuring may be in order.
One thrust of Trump’s second term has been a concerted effort to sideline the legal referees charged with checking abuses. Nearly a score of inspectors generals charged with addressing fraud and abuse have been summarily dismissed without cause. The Office of Government Ethics has been decapitated. The head of the U.S. Office of Special Counsel charged with enforcement of civil service laws, such as whistleblower protection, has been removed.
America did not intend to elect a dictator.
The net result is that violations of laws and ethics go unchecked because independent oversight has been neutralized. To prevent the recurrence of future lawless regimes, Congress should reinstitute some of the checks Mr. Trump has shredded but in a way that insulates them from unilateral executive reversal. Congress needs to strengthen the institutional guardrails against executive violations of ethical standards and for protection of federal employees from illegal actions and enforceable standards for scientific integrity.
One step would be a statute relocating inspectors general (IGs) within the legislative branch. IGs do not perform an inherently executive function as they lack authority to implement their recommendations. Congress should appoint fixed-term IGs and team them with the Government Accountability Office (GAO), another legislative body, to keep this strengthened watchdog function beyond executive obstruction.
In this restructuring, the independent IGs could also conduct scientific integrity reviews to resolve challenges to the accuracy of scientific and technical agency information. This would put control of scientific and technical data and analyses beyond the unilateral control of the very bureaucracies responsible for creating them and thereby prevent them from peddling disinformation. Moreover, uniform procedures would facilitate the use of expert scientists from other agencies, universities, and other institutions to serve as review panels.
Similarly, institutions charged with enforcing civil service protections, such as the Office of Special Counsel and the Office of Government Ethics, should be moved into the legislative branch, as well, to prevent them from executive nullification.
Most fundamentally, the executive should not be able to control the judges who decide on disputes the executive branch has with its employees, contractors, and others. Basic fairness requires that these referees be impartial and not under the direct control of one party in the disagreement.
These referee positions are also not inherently executive in nature. For example, under the Competition in Contracting Act of 1984, Congress designated its GAO to serve as an independent and impartial forum for the resolution of disputes concerning the awards of federal contracts. Similarly, investigations into and reviews of employment abuses and related disputes could be handled by statutorily relocated Offices of Special Counsel and Government Ethics.
Significantly, one of the more insidious recent Trump initiatives is asserting his authority to summarily remove administrative law judges (ALJs) who preside over hearings regarding administrative or legal disputes between federal agencies and affected parties. The prospect of removal at will undoubtedly pressures ALJs to alter their decisions to favor the executive agencies.
Mr. Trump is also attempting (once again) to sideline the Merit Systems Protection Board (MSPB), the civil service court which hears legal disputes about the illegal termination or treatment of federal employees. During his first term, President Trump shuttered MSPB by refusing to appoint any persons to fill MSPB vacancies. The three-member MSPB soon lost a quorum to decided cases and entered the Biden administration with a backlog of undecided appeals of more than 3,700 cases.
In his current term, Trump is trying the same approach, seeking to remove one of the two remaining MSPB members midway in her five-year term. As a result, the MSPB has once again been shuttered and may not reopen for years,
To enforce the basic rule of law, Congress should move the cadres of administrative law judges and the MSPB to the judicial branch so that the basic fairness of these decision-makers is safeguarded and they are shielded from further executive interference.
While President Trump may claim that he is implementing the will of the public, a recent Wall Street Journal poll found broad bipartisan support for limiting Trump’s unilateral executive authority. America did not intend to elect a dictator.
Yet, the principal takeaway from events of the past few months is that President Trump has conclusively demonstrated that the executive branch cannot be trusted to police itself in following the law. To prevent future presidents from assuming the same authoritarian posture as Trump, Congress must act decisively to fundamentally rebalance our system of checks and balances.
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