The Chainsaw Coming for Public Health: A Conversation with Jonathan Cohn

Mass firings at HHS and SAMHSA aren’t just bureaucratic shakeups — they’re dismantling the front lines of America’s overdose crisis.

Apr 06, 2025

Welcome back to the newsletter!

This week, I had the pleasure of sitting down with Jonathan Cohn, a sharp policy writer who’s just joined The Bulwark with his newsletter The Breakdown.

We dove into a topic that’s been on my mind lately: the Substance Abuse and Mental Health Services Administration (SAMHSA) and the ripple effects of recent federal cuts under the Trump administration.

For those who don’t know me too well yet, I’ve been hosting this podcast for a while now, but I also wear another hat: I work with Harbor Path, a nonprofit that distributes naloxone — the “Lazarus drug” that reverses opioid overdoses.

I’ve seen firsthand how fentanyl has torn through communities, especially here in West Virginia, where it’s the leading killer of folks aged 18 to 44.

College kids, rural families — it doesn’t discriminate.

So when Jonathan wrote about SAMHSA, an agency I’ll admit I hadn’t given much thought to until recently, I knew we had to talk.

Here’s what I learned — and why it’s got me worried.

What’s SAMHSA, Anyway?

SAMHSA isn’t a household name, and Jonathan assured me that’s okay — even he, a healthcare policy veteran, only clocked it on his radar a while back.

It’s a smaller federal agency, born in the early ‘90s, but it’s taken on a big role since the opioid crisis kicked into high gear about a decade ago.

Think of it as the quarterback for federal efforts on substance abuse and mental health. It hands out grants to states (like the one Harbor Path tapped to get naloxone onto college campuses), runs the 988 mental health hotline, and oversees the National Survey on Drug Use and Health—the gold standard for tracking drug trends.

In short, SAMHSA’s the glue connecting federal resources to the boots-on-the-ground folks fighting this epidemic. Or at least, it was.

The Cuts Hit Hard — If They Stick…

Here’s where things get dicey.

Right after Jonathan and I recorded this episode, this Politico Pro alert hit my Twitter (X) feed:

Health and Human Services Secretary Robert F. Kennedy Jr. said Thursday that he expects to reinstate some employees and programs that were cut under the administration's mass firings across its public agencies.
"At DOGE, we talked about this from the beginning ... we're going to do 80 percent cuts, but 20 percent of those are going to have to be reinstalled, because we'll make mistakes," Kennedy told reporters.

Let’s pause there. Set aside, for a moment, the head-spinning logic of firing swaths of people — only to then try and rehire some of them.

Until we see any real reversals, I have to assume the cuts Jonathan reported on last week are permanent.

And the fact remains: the Trump administration, now deep into its second act, has put RFK Jr. in charge of the Department of Health and Human Services (HHS) — the agency that oversees SAMHSA.

Between the “Make America Healthy Again” slogan and Elon Musk’s Department of Government Efficiency (DOGE), the cuts are coming fast and hard — 25% across HHS, with SAMHSA taking a brutal hit.

Some estimates suggest the agency has lost between a third and two-thirds of its staff. Entire divisions — like the one responsible for the cornerstone drug use survey — are simply gone. Vanished.

Jonathan noted something chilling: the regional offices — ten hubs that connected D.C. to communities across the country — have been slashed in half.

These weren’t just desk jobs. These folks were in the field, talking to local leaders, spotting emerging drug trends, and ensuring federal grant dollars didn’t get jammed in bureaucratic limbo.

Now, with just five offices left — and those gutted — the system for responding quickly and effectively is broken.

Where I live, if a rural recovery program misses a grant payment by a week, it might shut down. And in this fight, a week can mean lives lost.

Efficiency or Chaos?

The administration claims this is about cutting waste and making government leaner. And look, I believe in careful reform, not bloated bureaucracy.

But as Jonathan put it, these cuts feel “arbitrary.” There’s no clear plan, no transparency — just a fire sale on institutional knowledge.

Case in point: the National Survey on Drug Use and Health, covering Americans as young as 12, was published March 31. The team that produced it? Fired days later.

So who runs it next year? Who ensures continuity? Who makes sense of the data lawmakers rely on?

I’ve advised elected officials. They love data — it’s how you build smart policy. Without it, you’re flying blind. And in a crisis that’s already killed more than 700,000 Americans — first from Oxy, now from synthetic opioids — blindness isn’t an option.

Jonathan’s latest piece in The Breakdown over at The Bulwark is worth your time — he’s pulling the curtain back on policy in a way that’s clear, sharp, and sobering. I’m grateful he’s on the beat.

As for me? I remain skeptical of the RFK, Jr. regime — but hopeful. I want to see a real plan.

Until then, I’ll keep pushing naloxone, keep asking questions, and keep fighting for the folks who can’t fight for themselves!

News Roundup

And Finally …

Congratulations are in order former guest Drazen Jorgic. He was part of the Reuters team that just won an Overseas Press Club of America (OPC) award for their investigative series on fentanyl.

If you haven’t already seen it, this short excerpt will give you a sense of the importance of this kind of investigative journalism:

Follow Drazen Jorgic @Draz_DJ. Follow Jonatan Cohn @CitizenCohn.

Thanks for reading, y’all. Drop a comment — what’s on your mind?

Until next time,
Erin