When you ask public health advocates about President Trump’s recent budget proposal, you typically get a bewildered pause. Public health people don’t like to exaggerate — they follow the science, they stay calm, they face off against dangerous threats on a regular basis. Exaggerating doesn’t help contain diseases, it only makes it harder. So it’s concerning when you hear words like this about Trump’s budget: “devastating,” “not serious,” “ludicrous,” “unfathomable.”
Released in late May, Trump’s fiscal year 2018 federal budget proposal calls for cutting the budget at the Centers for Disease Control and Prevention by $1.2 billion — that’s a cut of 17 percent. Then take into account funding that CDC gets through the Affordable Care Act’s Prevention and Public Health Fund. That fund, which under the GOP-proposed American Health Care Act would disappear at the end of FY 2018, currently makes up 12 percent of CDC’s budget and provides more than $620 million yearly to state and local public health. Combined, it means the White House is currently supporting budget and legislative efforts that would essentially cut one-third of CDC’s budget.
Of course, no one believes that Trump’s budget will make it out of Congress intact — in fact, no one thinks Congress will even pass a budget. But Emily Holubowich, executive director of the Coalition for Health Funding, reminded me that regardless of how Congress receives the Trump budget, lawmakers are facing the return of sequestration. That means mandatory budget cuts of billions of dollars unless members of Congress act to provide sequestration relief as they have the past few years.
“They’ll need to cut from somewhere and they’ll look to the president’s budget to get ideas,” she said. “Where we run into trouble is thinking this budget won’t go anywhere anyway. But we shouldn’t assume this budget has no life.”
The cuts in Trump’s CDC budget proposal are deep and troubling. They include, but are certainly not limited to:
- a more than $220 million cut to chronic disease prevention (chronic diseases are a leading cause of death in the U.S. and a major driver of health care spending);
- a cut of $136 million from public health preparedness and response (that’s the funding that sustains public health’s capacity to respond to emergencies like Zika, pandemic flu and Hurricane Katrina);
- a cut of more than $186 million for work related to HIV/AIDS, hepatitis, STDs and tuberculosis;
- a more than $89 million cut to CDC’s immunization program;
- a nearly $25 million cut to the National Center for Environmental Health, including an elimination of its climate and health program;
- elimination of the $51 million Racial and Ethnic Approaches to Community Health program, which addresses disparities in infant mortality, cancer, heart disease, diabetes, HIV/AIDS and immunizations;
- elimination of the $160 million Preventive Health and Health Services Block Grant, which state, local and tribal public health agencies use to address localized public health problems;
- a $138 million cut to occupational health and safety programs;
- a more than $76 million cut to global health programs, with most of those cuts coming from global HIV/AIDS efforts; and
- a nearly $65 million cut to emerging and zoonotic diseases, including cuts to efforts to combat antibiotic resistance.
“Cuts of this magnitude, even taking the Prevention Fund aside, are completely unfathomable,” Holubowich said. “Frankly, I just don’t know how you carry on a lot of public health’s core functions. You’d have to assume some reduction in workforce, and the trickle-down effect to state and local public health would be furloughs, laying people off, not hiring. I don’t know how you function at that point.”
Keep in mind, the public health workforce has already lost significant numbers and funding. According to the National Association of County & City Health Officials (NACCHO), local public health has lost 22 percent of its workforce since 2008. The Trust for America’s Health reports that federal funding for disease prevention and health promotion has already dropped by $580 million since 2010 and remained flat at the state level. On Trump’s CDC proposal, former CDC Director Tom Frieden tweeted: “Proposed CDC budget: unsafe at any level of enactment. Would increase illness, death, risks to Americans, and health care costs.”
Holubowich said she expected the proposal to be bad, but she was still surprised by cuts like the $136 million one to public health preparedness, especially considering the White House’s focus on national security and defense.
In fact, 55 percent of local health departments depend solely on federal funding to support their preparedness activities — funds they rely on every day to respond to all sorts of emergencies, from hurricanes and floods to measles and foodborne illness outbreaks, said Laura Hanen, interim executive director and chief of government affairs at NACCHO. Another big blow at the local level, Hanen told me, would be elimination of the Preventive Health and Health Services Block Grant, a flexible source of funding that supports communities in addressing their unique public health problems. (Most federal public health funding is categorical or disease-specific, so losing flexible funding is a big deal.)
“It’s a devastating cut across the board,” Hanen said. “The president’s budget is essentially a values document — it lays out the values of the White House in terms of what they’d like to see. …I think we all have to take it very seriously.”
Among the more disappointing proposed cuts, Hanen pointed to the $222 million cut to chronic disease prevention, noting that “disinvesting in efforts to prevent people from getting costly chronic diseases is pennywise and pound-foolish.” Another troubling proposal, she said, is the big cut to the CDC immunization program, which supports local public health workers in sustaining protective immunization rates and responding to vaccine-preventable outbreaks. Hanen added that such at-risk programs become even more important if millions of Americans lose their health insurance under the Republican ACA replacement and once again look to public health for clinical safety net services.
“We cannot sit silently by and not speak out and say this is bad for the country,” Hanen said, adding that “I believe Congress understands and values the public health programs that they’ve been supporting for decades, and I believe they will continue to do so.”
At the Association of Public Health Laboratories, Peter Kyriacopoulos, senior director for public policy, said his first reaction to the White House budget document “was that this is not a serious budget proposal.” He said the idea that CDC, along with state and local public health, could withstand a cut more than $1 billion and still properly function is “ludicrous at best.”
“That said, I do think the budget request is a very useful tool because it makes real a lot of these previously vague suggestions about massive cuts to the federal government — this shows us what it means to come up with a $54 billion cut to nondefense spending,” Kyriacopoulos told me. “I think many people will have questions at best and will outright disagree with it at worst.”
Of particular importance to public health labs — these are the labs that provide critical diagnostic data so officials can rapidly detect, monitor and contain dangerous disease outbreaks — is the $40 million in yearly funding from the Prevention and Public Health Fund to CDC’s Epidemiology and Laboratory Capacity (ELC) Program. If the Prevention Fund goes away in 2019, as is proposed in the American Health Care Act, so too does that ELC funding. Another troubling proposal, Kyriacopoulos said, is the cut to global health, which undercuts efforts to ensure that local disease outbreaks don’t become global ones.
Kyriacopoulos, like his fellow public health advocates, predicts that because of the gridlock in Congress, we’ll likely end up with another continuing resolution, which continues funding at current levels. And in the current policy climate, that might be the best-case scenario for public health.
Still, all three advocates — Kyriacopoulos, Hanen and Holubowich — said it’s time for public health to speak up, tell its stories and talk loudly about the value of its work.
“My philosophy is just do anything,” Holubowich said. “Go to a town hall meeting, write your member of Congress, call them, call the media and tell your story. …There’s a saying in Washington that if you’re not at the table, you’re on the menu. Public health needs to be at the table. We can’t sit idly by.”