At the surface, Congress is a total mess. Below, it’s actually getting some big stuff done.
On December 23, while many of us were doing last-minute holiday shopping, Congress passed a big $1.7 trillion spending package, keeping the government funded through September 30, which marks the end of this fiscal year. You’ve likely heard of some of the bill’s more newsworthy provisions, such as a change to the Electoral Count Act to prevent an attempt like Donald Trump’s in 2021 to overturn a presidential election result, or the $45 billion in support for Ukraine’s defense against Russia’s invasion.
But tucked into the package was a surprisingly large boost in funding for something that doesn’t usually generate headlines: global health programs. The Global Fund to Fight AIDS, Tuberculosis, and Malaria, an international organization that provides financing for country-level programs like drug distribution and bednets in developing countries where those diseases are widespread, saw its funding from the US grow from $1.56 billion to $2 billion, a more than 28 percent year-over-year boost. Funding for USAID’s Global Health Programs, which include nutrition programs, efforts against infectious disease, and more, rose from $700 million to $900 million, and the Centers for Disease Control and Prevention’s Global Public Health Protection division, which works abroad to strengthen health systems’ ability to respond to outbreaks, saw a $40 million boost as well.
An analysis by the Center for Global Development finds that global health support from the State Department and USAID grew overall from $9.83 billion in fiscal year 2022 to $10.56 billion in 2023, a 7.4 percent increase.
These numbers are not huge in the context of a $1.7 trillion spending bill, but they’re significant. “What was interesting about FY23 in the omnibus was that almost all global health areas increased, with the exception of family planning,” Adam Wexler, associate director of global health and HIV policy at the Kaiser Family Foundation, told me. (Family planning funding tends to be particularly fraught given how heated debates over abortion and birth control are in Congress.)
And the increases stand out for another reason: They’re bipartisan. Global health funding has a number of Republican champions in Congress, like Rep. Hal Rogers (R-KY), the outgoing ranking member of the appropriations subcommittee handling foreign aid funding; Rep. Michael McCaul (R-TX), who chairs the Committee on Foreign Affairs; and Rep. Ann Wagner (R-MO), McCaul’s deputy on that committee, among others. “The Global Fund has been one of the most successful programs in the history of government,” as Sen. Lindsey Graham (R-SC), the head Republican on the Senate appropriations subcommittee covering the fund, once said.
On February 22 of last year, McCaul and Rep. Barbara Lee (D-CA), then the chair of the appropriations subcommittee and the leading Democrat on these issues, organized a letter from 137 members of the House to President Biden asking for a “robust and increased three-year US pledge” for the Global Fund. Twenty-one of the signatories were Republicans, including not just moderates but Trump-loyalist members like Reps. Elise Stefanik (R-NY) and Joe Wilson (R-SC) (the same guy who yelled “you lie!” during one of Obama’s addresses to Congress).
This may seem unusual in a Congress that can’t seem to agree on anything — but it isn’t. Global health funding has in fact been a major area of bipartisan cooperation for years, so far mostly avoiding Congress’s increasing polarization on many other, higher-profile issues. And it’s managed that in part because it has remained under the radar and received little press attention.
It’s a prime instance of what Simon Bazelon and Matt Yglesias have called Secret Congress: an area where legislators are able to make progress out of the media spotlight, on issues that don’t inflame public passions. And given how progress on killer global diseases has slowed in recent years, putting millions of lives at risk, we should hope that this pattern continues.
How Secret Congress saved lives
While global health funding saw boosts across the board in the FY2023 omnibus, the star of the show was the Global Fund. Founded in 2002, the fund is a multilateral organization that collects money from governments and private donors (principally the Bill & Melinda Gates Foundation) and disburses it to local groups working on HIV/AIDS, TB, and malaria. The fund has always received bipartisan support. It was founded partially at the impetus of, and with significant funding from, the George W. Bush administration. That support continued during the Obama years. While the anti-globalist Trump administration sought massive cuts to the US contribution — especially worrying given that the US is the fund’s single biggest donor, providing over a third of its resources — Congress, with the help of Republican members like Rogers, McCaul, and Wagner, rejected them.
The fund plans on the basis of “replenishments” every three years, during which donors negotiate pledges for funding the subsequent three years of efforts. The funding boost this year originated in the Biden administration’s efforts for the seventh replenishment. For one thing, the United States agreed to host the Replenishment conference last year from September 19 to 21 in Washington, a major signal of US support for the global development community.
On March 28, the administration released its FY2023 budget proposal, which included its proposal for $2 billion in annual funding for the Global Fund and an overall $6 billion three-year pledge. This was followed in June by the House Appropriations Subcommittee for State, Foreign Operations, and Related Programs (SFOPS), then led by Rep. Barbara Lee and ranking member Rep. Hal Rogers, approving the $2 billion for 2023. In July, the Senate Appropriations Subcommittee, chaired by Sen. Chris Coons (D-DE) with ranking member Sen. Graham, did the same.
Chris Collins, president of Friends of the Global Fight, which advocates for increased Global Fund commitments from the US, told me the Biden administration effort was led at a high level, with Secretary of State Antony Blinken and National Security Adviser Jake Sullivan playing active roles.
The US is represented at the Global Fund by John Nkengasong, who serves as US global AIDS coordinator and special representative for health diplomacy, and Loyce Pace, assistant secretary for global affairs at the Department of Health and Human Services. Nkengasong is a remarkable figure; Cameroonian by birth, he’s a virologist who in his doctoral research was the first to identify the genetic subtypes of HIV in circulation in Africa. He was also the first leader of the Africa CDC in Ethiopia, an attempt to build a version of the US CDC in Africa, and organized the continent-wide response to Covid.
The push for a major investment was partly a result of concerns that the Covid pandemic would overshadow existing health threats. “The administration did not want to be seen to favor future pandemic risk preparedness (and the newly established Pandemic Fund) at the expense of existing global health priorities like [Global Fund] that remain hugely important,” Amanda Glassman, executive vice president and senior fellow at the Center for Global Development, told me. “The US was trying to make the case that the global community should do both.”
The multilateral nature of the fund also meant that the administration could leverage its pledges: If it pledged more, it could convince partner countries to pledge more in turn. Under US law, the country can’t fund more than one-third of the Global Fund’s total budget, which effectively means that when the US increases funding, other donors have to match it 2:1 if they want to keep the US funding. The nearly 30 percent increase in the US pledge helped spur an overall three-year pledge total of $15.7 billion, compared to $14 billion in the sixth replenishment. And because the Global Fund requires recipient countries in sub-Saharan Africa and South Asia to increase funding for the health of their own people, the US-led boost is “leveraging both other donors and implementing countries to do more and take on more of the burden,” Collins explained.
How effective is it?
Increasing funding for measures against HIV/AIDS, malaria, and tuberculosis is of course a good thing. But how big a deal it is depends on how effectively the money is spent.
While the Global Fund has argued that its work thus far has saved at least 50 million lives over the past 20 years, the truth is that there have been no compelling, independent studies estimating the fund’s impact on mortality. The Global Fund does provide money for programs that we know on a micro level save lives, like antiretroviral drugs for HIV and bednets and preventive treatments for malaria, to the tune of tens of billions of dollars. That should save many, many lives, but the 50 million number is at best an educated guess, the sort any nonprofit likes to make when it’s asking for funding.
Glassman argues the fund could be doing more to prioritize investments in cost-effective interventions, and maximize the impact it can get from the increased level of funding. While progress against both malaria and HIV has been slowing in recent years, it seems that Covid is not principally to blame, suggesting that something else is going wrong with the world’s response to these diseases. “The [Covid] disruption in services was pretty minimal in most of [sub-Saharan Africa] except for childhood immunization,” Glassman said. “Unfortunately, the cost-effectiveness of the different procurement and delivery strategies utilized by the different [Global Fund] grantees is not studied or reported by the [Global Fund] or UNAIDS, and these issues are inexplicably absent from the discussion during replenishments.”
Some of the problem is a lack of data. The Global Fund works directly with NGOs and government agencies in affected countries, and those countries’ spending patterns are often opaque, making it hard to estimate how much a given intervention cost, and how much in the way of public health improvements a given dollar spent on that intervention can produce.
Elsewhere in the aid budget, Congress has put a big emphasis on improving evidence bases and scaling up evidence-based projects. Development Innovation Ventures, a project at USAID meant to identify particularly cost-effective interventions, got a funding bump from $30 million to $40 million. The task in the future will be trying to expand these initiatives so that multilateral projects like the Global Fund get more scrutiny, too.
That requires continued support from the odd bedfellows in Congress that have sustained the fund and related programs for decades. Ultimately, when asked, Republicans in the House and Senate explain their support for the Global Fund and global health funding in the same terms that Democrats and global health practitioners do: they think it saves lives, and that that’s a worthy use of their role in office. “Most people want to make sure their taxpayer dollars go to a good cause. Once you understand what the Global Fund has done, and can do and will do, the critics kind of melt away,” Graham said at an event where he was honored for his support for the fund.
“It’s the best thing that I’ve been able to do” as a member of Congress, Rep. Kay Granger (R-TX), now the chair of the House Appropriations Committee, said at that same event.
The Republican caucus for global health is at least partially a legacy of the George W. Bush years. The then-president made infectious diseases in poor countries a key priority, launching the Global Fund and President’s Emergency Plan for AIDS Relief (PEPFAR), which have dedicated over $110 billion to date to fighting HIV, malaria, and tuberculosis. He also launched the President’s Malaria Initiative (PMI) in 2005, substantially increasing resources fighting that disease specifically. One study estimated that PMI specifically prevented 185 million cases of malaria and saved 940,049 lives from 2005 to 2017; multiple studies have found that PEPFAR reduced deaths from all causes by about 20 percent in countries receiving assistance, translating to millions of lives saved.
Shortly before Congress approved its major package of global health funding, Michael Gerson, the Bush administration speechwriter credited as a driving force behind those programs, died of cancer at 58. He wrote a whole book, Heroic Conservatism, that among other things distilled the conservative case for investing in global health. In it, he recounts the story of a friend visiting an HIV and AIDS clinic in Zambia in 2005, where patients told her they came “because we heard the Americans are going to help us.” Gerson continues: “That is a familiar refrain in history. In Nazi-occupied Europe … in the gulags of the Soviet Union … there were many who said, ‘We heard the Americans are going to help us.’ That is what America has been, and should always be.”
A new study found dire consequences for Medicaid patients when a public hospital is taken over by a private company.
Over the past four decades, US hospitals have gradually moved from public hands to private ones. The share of hospitals owned and operated by a government body — as opposed to a private entity, either a for-profit enterprise or a nonprofit — declined by 42 percent from 1983 to 2019.
That trend has brought serious consequences for the poorer patients who seek care at these hospitals. When private companies assume control of public hospitals, low-income patients on Medicaid lose access to health care, according to new research on this longstanding but under-analyzed trend in American health care.
A new National Bureau of Economic Research working paper by academics from Stanford, Michigan State, and Penn reviewed the consequences of the 258 hospital privatizations from 2000 to 2018 they could identify using national data. (As there were a little more than 1,000 public hospitals in 1999, that would mean one-fourth of all US public hospitals were privatized over the period they studied.)
These researchers found that after a private company took over a hospital previously controlled by the government, the hospital becomes more profitable. As a public hospital, these facilities lost about $335 on average for every patient. As a private hospital, they earned about $740 per patient.
In an ideal world, hospitals could be operating more efficiently, and therefore more profitably, without sacrificing access to health care. And the researchers do find that the hospitals achieve greater profitability in part by reducing spending on administrative and support personnel rather than people most directly involved in patient care. There was no meaningful reduction in nursing staff, for example, after the transfer of control.
But the other way in which these hospitals increased their profitability is more worrisome. Hospitals taken over by private companies saw an 8.4 percent decrease in overall patient volume, partly the result of hospitals reducing their capacity in a likely bid to improve efficiency.
Admissions for Medicare dropped by only 5 percent, a statistically insignificant change, according to the researchers. But Medicaid admissions fell by 15 percent, as did the decline in “other” admissions (which include the uninsured and private insurance, with the former representing another unprofitable business line for hospitals). Though Medicaid patients made up 20 percent of patient volume at these hospitals, they accounted for 30 percent of the drop in admissions after privatization.
“These patterns are consistent with private owners wanting to reduce the share of Medicaid and Other patients at their hospital in order to increase mean revenue per patient,” write the paper’s authors.
I asked the authors what hospitals turning away Medicaid patients might look like in practice. They could only speculate, as that was beyond the scope of the paper, but Mark Duggan at Stanford told me that perhaps the most straightforward way would be for them to decline to renew their Medicaid contracts, taking the hospital out of the provider network for Medicaid patients. Atul Gupta at Penn also said that they could cut certain lines of service, such as psychiatric care, that are more frequently used by Medicaid patients. Or they could decline to admit Medicaid patients; while they are obligated to stabilize a patient in the emergency room, they have more discretion about which patients to actually admit into the hospital.
In theory, fewer Medicaid patients could mean simply that there are fewer unnecessary hospitalizations. But the researchers tested that idea by examining what happened to patient volume across an entire area when a hospital was privatized. They found patients with Medicare or private insurance were absorbed by the neighboring hospitals — but Medicaid admissions dropped across the region.
In other words, when newly privatized hospitals decreased admissions, the patients with more lucrative health insurance were picked up by other facilities, which would suggest they still had clinical needs that the market then rose to meet. But Medicaid patients, whose insurance is not as generous, simply lost access to health care.
“The aggregate decline in Medicaid volume potentially hurts its effectiveness as a social insurance program that ensures access to medical care for vulnerable low-income beneficiaries,” the researchers write. “Privatization therefore emerges as a channel that may curb utilization of care by Medicaid beneficiaries.”
The consequences of hospital privatization for Medicaid patients have gained more importance given the recent expansions of Medicaid eligibility. Medicaid has now grown to become the single largest health insurer in the United States, covering more than 90 million Americans (including the related CHIP program that covers kids). But, as the authors noted in their analysis, that rise in enrollment has not been matched by a commensurate increase in hospital admissions by Medicaid patients. Their findings may help to explain why.
Medicaid is vital to the US safety net, providing zero-cost insurance coverage for low-income Americans. It also has its problems, with low reimbursement rates leading fewer doctors to accept Medicaid patients. One of the most interesting research papers from last year found that supposedly “adequate” physician networks for people enrolled in Medicaid managed care plans (which are overseen by private companies) were not as robust as they first appeared to be.
Giving people Medicaid coverage is the first step to making sure vulnerable Americans get the health care they need — but it is only the first step. They need to find doctors and hospitals that will accept their insurance and treat them. That has been a longstanding struggle because of the program’s low reimbursement rates, which are substantially less than Medicare or private insurance.
And, according to this new research, the trend toward hospital privatization is making the problem worse.
The role of the special counsel is designed to avoid potential conflicts of interest.
US Attorney General Merrick Garland announced Thursday that he was appointing a special counsel to investigate why classified materials were found at President Joe Biden’s home and a former private office.
Robert Hur, a former US attorney in the Trump administration, will take over the investigation. Biden said he is cooperating. Hur will be tasked with determining whether there were any crimes committed in the course of handling the classified materials, which date back to Biden’s tenure as vice president, and are therefore the property of the federal government under the Presidential Records Act.
It’s not the first time in recent months that Garland has called on a special counsel. He also appointed one to investigate former President Donald Trump’s withholding of classified material found at his Florida residence at Mar-a-Lago.
It’s a role that is designed to act at a distance, but not entirely independently, from the Justice Department to avoid the appearance of impropriety in cases where there might be a conflict of interest. Here’s what you need to know.
When is a special counsel required?
Justice Department regulations require the attorney general to consider appointing a special counsel when a criminal investigation of a person or matter is warranted, and when the DOJ may face a conflict of interest in carrying out such an investigation itself; for example, if the attorney general or another member of the executive branch is under investigation. Special counsels are also required when there are other “extraordinary circumstances” that make it in the public interest to appoint a special counsel, such as a sitting president being under investigation. Garland said Thursday extraordinary circumstances existed in Biden’s case.
It’s not yet clear whether Biden committed any crimes by storing classified documents outside of secure federal facilities; that’s something the special counsel will look into. That Biden is now the president, and that an investigation is underway into former President Donald Trump for mishandling classified documents, makes this a particularly high-profile inquiry. But it’s not unusual for the DOJ to open an investigation in this kind of case.
“Any time classified materials go to a place they’re not supposed to go, there is almost always an inquiry into how they got to that place,” said Kristy Parker, the former deputy chief of the criminal section of the DOJ’s civil rights division and now counsel at Protect Democracy, an organization that seeks to check authoritarian attacks on American democracy. “The department always takes that really seriously.”
Garland was appointed by Biden and, if he were to lead the investigation, that history could present a conflict of interest. That’s likely the primary reason why Garland handed over the investigation to a special counsel. It’s also likely why Garland chose Hur, who was not associated with the Biden administration. (Notably, Garland didn’t appoint a special counsel to investigate the mishandling of classified documents found at Trump’s property until the former president announced his 2024 candidacy, making him Biden’s political opponent and creating a potential conflict of interest.)
“What’s really crucial in a democracy is to have the nation’s primary law enforcement agency operating to the greatest extent possible free of any partisan politics,” Parker said. “So my view is that he is acting appropriately to put someone in charge of this investigation who is not someone who was appointed by Joe Biden or who was already working in the department that the Biden administration oversees.”
What are the powers and limitations of the special counsel?
The special counsel has all the same powers that a US attorney would have to conduct a criminal investigation: for example, subpoenaing witnesses and documents, directing federal agents to conduct investigative activities, and seeking a warrant in court. But there are some limitations to those powers, in that the special counsel is required to consult with the attorney general on major decisions.
“While he’s at arm’s length from the attorney general and he’s not an employee of the current Department of Justice, he still reports to the attorney general. It’s ultimately the attorney general’s final call as to whether a case should be indicted or closed,” Parker said.
Regulations don’t require the recommendations of the special counsel to be made publicly available. But if the attorney general goes against the special counsel’s recommendations, they must report that to Congress after the investigation concludes, and then lawmakers can publicize that decision.
In the case of special counsel Robert Mueller’s investigation into Russian interference in the 2016 election, his findings were made public — but only after then-Attorney General Bill Barr issued his own summary that downplayed the extent of Trump campaign associates’ contacts in Russia and evidence that Trump obstructed justice.
It might not make sense to make the findings publicly available in cases where the DOJ is seeking an indictment, so as not to reveal all of the evidence before taking the case to court. But in cases where the DOJ declines to prosecute, “it’s customary and, in my view, in the public interest, to explain that to the public,” Parker said.
Whether that will happen in Biden’s case is still unclear, as is the timeline for concluding the investigation. But so far, Parker said that the DOJ is functioning as it should.
“I think this is a really important step by the attorney general to do what he said he was going to do when he was appointed, which is to restore the department’s reputation as an independent law enforcement agency,” she said.