President’s budget plan offers mixed outlook for public health: CDC slated for $194 million decrease
======================================================================================================

* Lindsey Wahowiak

With the release of his fiscal year 2017 budget request on Feb. 9, President Barack Obama set the tone for the next year of U.S. spending. But the impending elections could put a wrench in funding plans.

APHA’s reaction to the budget proposal was mixed. The president’s $1.1 billion proposal for new mandatory funding to combat prescription opioid and heroin use was cause for celebration, as it would provide much-needed preventive services and treatment for people with opioid abuse disorders. Notably, it also called for Centers for Disease Control and Prevention programs to battle antibiotic resistance, fund gun violence prevention research and address prescription drug abuse; Health Resources and Services Administration programs to improve family planning; and Food and Drug Administration programs to improve prevention-based food safety systems.

But the budget proposal also calls for a decrease of $194 million for CDC, including the elimination of the Preventive Health and Health Services Block Grant, and cuts to the 317 immunization program, the National Environmental Public Health Tracking Program and the Racial and Ethnic Approaches to Community Health Program. The budget request also would eliminate HRSA’s Area Health Education Centers Program, which supports primary care, workforce diversity and health care quality training and improvement in underserved areas.

In a Feb. 9 news release, APHA Executive Director Georges Benjamin, MD, said there were high and low points in the budget.

“We welcome the administration’s efforts to tackle emerging health threats,” Benjamin said. “But plain and simple, we’re going to need a strong and sustained investment in public health to create the healthiest nation in one generation.”

Still, there was much to support in Obama’s proposed budget. For example, the Center on Budget and Policy Priorities noted in a Feb. 9 blog post that the budget included “sound improvements” to Medicaid and the Children’s Health Insurance Program, including three years of full federal financing for all states that expand Medicaid. It would also extend CHIP funding through 2019, called for equitable Medicaid funding for Puerto Rico and included a Medicaid payment boost for primary care. The budget also included two proposals “to cut red tape and enroll more eligible children in Medicaid and CHIP” through Express Lane Eligibility, a state option that allows states to use data already collected to establish people’s eligibility in other programs, such as the Supplemental Nutrition Assistance Program.

The budget also calls for a $40 million increase in funding for CDC infectious disease funding, money that would be used to fight antibiotic resistance by expanding CDC’s established antibiotic resistance prevention programs from 25 states to all 50. Jonathan Nurse, MPP, director of government relations for the Infectious Diseases Society of America, said it was heartening to see the administration continue its commitment to working on the growing problem, particularly when about half of antibiotics that are currently prescribed are not medically necessary.

“The 2017 request does carry forward much of the investments that were made in 2016,” Nurse told *The Nation's Health.* “The fact that the administration seeks to continue the programs they started in 2016 is a positive sign for us.”

Public health advocates also celebrated the budget’s proposed funding to fight opioid addiction and overdose. CDC reports that 44 Americans die from prescription opioid overdose daily, and that the amount of prescription painkillers that are prescribed in the U.S. has quadrupled since 1999.

The president’s 2016 budget proposal included an investment of more than $100 million across a variety of agencies, including CDC, said APHA member Richard Hamburg, MPA, interim president and CEO at Trust for America’s Health. This year’s proposed budget would continue that investment, while also increasing discretionary spending from $70 million to $80 million, which would allow CDC to expand its work with state health departments, from five states to all 50 and the District of Columbia, Hamburg said.

Particularly notable about this year’s proposal are large investments for Medicaid and treatment programs, which Hamburg called “vital.”

A Feb. 9 news release from the Indian Health Service also praised the budget request, which called for $6.6 billion for IHS, an increase of $402 million above fiscal year 2016 and 53 percent more since fiscal year 2008. The proposal would work to end longstanding health disparities among American Indians and Alaska Natives compared with other Americans.

“This budget accurately reflects the challenges the Indian health system faces in providing comprehensive health care and public health services in some of the most remote parts of our country,” said Robert McSwain, MPA, IHS principal deputy director. “(The funds would help provide resources that) are necessary to raise the physical, mental, social and spiritual health of American Indians and Alaska Natives to the highest level.”

Beyond APHA’s concerns, public health advocates have other issues with the administration’s suggested funding for the new fiscal year. On Feb. 10, the HIV Medicine Association announced it was “disappointed” that funding for domestic HIV and AIDS programs did not see an increase for the third year in a row. The association also noted that funding for the President’s Emergency Plan for AIDS Relief has not increased since 2010.

The proposed budget would reduce funding for research on diabetes, multiple sclerosis and other diseases, according to Research!America.

But the proposal also continues funding for reproductive health programs, including Title X and the Personal Responsibility Education Program, according to a release from Planned Parenthood Federation of America. Cecile Richards, the organization’s president, said the proposal could have gone further.

“This budget is a good first step and more work needs to be done,” she said in a release. “The Zika outbreak and its harmful effects on women and children also serve as a stark reminder of the global need for sexual and reproductive health care.”

## Fall elections could stall budget process

Obama’s budget request now heads to Capitol Hill for congressional approval, where ordinarily it would be challenged, with Congress raising its own priorities. House and Senate appropriation bills, totaling 12 in number, would be passed through both chambers of Congress, to be signed into law by the president by Oct. 1.

But heading into a presidential election, the likelihood of a budget passing is very weak, said Emily Holubowich, MPP, executive director of the Coalition for Health Funding and APHA member. Congress is only in session for 100 days this year, allowing members to campaign in their home districts, so time is of the essence. The death of Supreme Court Justice Antonin Scalia on Feb. 13 also nearly ensures partisan infighting that may hinder progress on passing a fiscal year 2017 budget, she said.

“In general, a president’s budget is always just a wish list,” she told *The Nation's Health.* “Certainly, any Congress is never going to (fully support) a president’s proposal. With the election, and certainly now with the death of Justice Scalia…I think we can expect the politics around this (to escalate).”

Holubowich predicted that instead of passing a budget, Congress will propose a continuing resolution — appropriations legislation that allows money for specific departments, agencies and programs to continue at the current level. In recent years, resolutions have gone on for a year at a time. That can be a risk for health programs, where grantees and contractors may be uncertain of whether or not they will receive funding.

For more on the budget, visit [www.whitehouse.gov/omb/budget](http://www.whitehouse.gov/omb/budget). Take action by sending a message to Congress at [www.apha.org/advocacy](http://www.apha.org/advocacy).

*   Copyright The Nation’s Health, American Public Health Association