President’s 2018 budget devastating to public health: Cuts to prevention, research, programs
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* Kim Krisberg

Even though it is unlikely that President Donald Trump’s 2018 federal budget proposal will be enacted as released, its massive cuts still represent a starting point for negotiations. And that is what worries public health advocates.

“Americans already live shorter lives and suffer more health problems than our peers in other high-income countries,” said APHA Executive Director Georges Benjamin, MD, in an APHA news release on the March 16 budget proposal. “To become a healthier and more secure nation, we must invest in the health and safety of everyone, and not just in our military. Further cuts to the critical programs funded through discretionary health funding put us further away from this goal.”

Trump’s brief budget outline — a more detailed proposal is expected from the White House this month — recommends cutting funding for the U.S. Department of Health and Human Services by $15.1 billion, or nearly 18 percent. The proposal is short on details, but states the federal budget still “supports” direct services, such as those delivered by community health centers, Ryan White HIV/AIDS providers and the Indian Health Service, though it does not mention specific funding numbers. The proposal states that the federal budget “supports efficient operations” of Medicare, Medicaid and the Children’s Health Insurance Program. Among those programs, the only funding number offered is a proposed $70 million increase to the Centers for Medicare and Medicaid’s Health Care Fraud and Abuse Control program. The budget also calls for a $500 million increase over 2016 levels for opioid abuse and treatment.

For public health in particular, the federal budget states that it “reforms key public health, emergency preparedness and prevention programs.” The proposal states the budget “restructures similar HHS preparedness grants to reduce overlap and administrative costs and directs resources to states with the greatest need.” The budget said it will create a new federal emergency response fund for fast response to public health outbreaks such as Zika. It also said it “reforms” the Centers for Disease Control and Prevention through a block grant.

Emily Holubowich, MPP, executive director of the Coalition for Health Funding, put the proposed 18 percent HHS cut in broader context, noting that during the 2013 budget sequestration in which agencies were cut across the board, HHS only absorbed about an 8 percent cut.

“So now we’re talking more than double that in one year,” Holubowich told *The Nation’s Health.* “It’s really unfathomable and not implementable.”

She also noted that the potential loss of the Prevention and Public Health Fund, which is targeted under Congress’ work to repeal the Affordable Care Act, would represent an additional 12 percent loss to CDC’s budget. If CDC had to absorb the kinds of combined cuts supported by the White House as of late March — a total cut of nearly one-third — Holubowich said it could “completely erode the safety net system — you’re looking at a tidal wave of need that would completely subsume the system.” On the proposal to block grant CDC’s budget, she predicted the funds would come from reallocating existing resources.

John Auerbach, MBA, president and CEO of Trust for America’s Health, said if CDC actually experienced the combined cuts it faced as of March, it would impact virtually all areas of public health, from responding to emerging disease outbreaks to partnering with hospitals to reduce health care-associated infections. He said turning CDC’s budget into a block grant would likely result in much less funding support for state and local public health. On the proposal for a new emergency response fund for outbreak response, Auerbach said it would certainly be “advantageous” to have a pot of money for crises like Zika and Ebola. However, he is concerned that money for the fund would be pulled from other public health programs.

“It was very disheartening to see just how enormous and sweeping the cuts were in so many areas of the budget that have a direct impact on the health and well-being of the American people,” Auerbach told *The Nation’s Health.*

Noting that health is shaped by a variety of social and environmental factors, Auerbach said cuts to other federal agencies would negatively impact health as well. Trump’s 2018 budget proposal recommends cutting the U.S. Environmental Protection Agency budget by 31 percent over 2017 levels. In particular, the proposal eliminates funding for the Clean Power Plan, global climate change programs and climate change research and partnership programs; reduces monies for the Superfund account by $330 million; and reduces EPA enforcement and compliance by $129 million.

Lynn Moseley Alexander, MPA, assistant vice president and director of the Healthy Air Campaign at the American Lung Association, said a 31 percent cut at EPA could translate into the loss of 3,200 staff positions and an “enormous step backwards” in addressing pollution and climate change, adding that the Clean Air Act is one of the most critical public health laws on the books. She also said the proposed elimination of climate change funding reflects a “misguided denial” of climate science.

“It is absolutely, critically important to meet the challenges of climate change in order to protect the air we breathe and the progress we’ve made,” Alexander told *The Nation’s Health.*

At the Department of Labor, Trump proposes a 21 percent decrease from 2017 levels, including eliminating the Occupational Safety and Health Administration’s Susan Harwood training grants, which the agency administers to reach workers in high-hazard industries who are particularly vulnerable to workplace injury, illness and fatality.

Jordan Barab, MA, who served as deputy secretary at OSHA from 2009 until Trump’s inauguration in January, told *The Nation’s Health* that a 21 percent cut to the Department of Labor “would be devastating to worker protection enforcement.” He noted that OSHA is already a small, understaffed agency. In fact, he said at current staff levels, it would take OSHA 145 years to inspect every workplace under its jurisdiction.

“Injury and illness on the job has gone way down since OSHA was created (in 1971),” said APHA member Debbie Berkowitz, who previously served as OSHA chief of staff and is now senior fellow for workplace safety and health at the National Employment Law Project. “Without it, the result is more workers will get killed and injured on the job.”

Back to the HHS budget, the White House proposes cutting the National Institutes of Health’s funding by $5.8 billion. David Pugach, JD, vice president of federal relations at the American Cancer Society Cancer Action Network, said the NIH cut “went well beyond our wildest fears,” adding that cuts of such magnitude would translate to a $1 billion cut to cancer research in particular. Pugach said the vast majority of cancer research at institutions across the country is funded via NIH, and private industry simply could not — or would not for financial reasons — make up for that kind of budget gap.

At the U.S. Department of Agriculture, Trump proposed a 21 percent cut. Among the details, the outline calls for “fully funding” the Food Safety and Inspection Service as well as $6.2 billion for the Special Supplemental Nutrition Program for Women, Infants and Children, which is a drop of $150 million from fiscal year 2016.

Douglas Greenway, MDiv, MArch, president and CEO of the National WIC Association, told *The Nation’s Health* the proposal recognizes a decline in WIC caseloads as the economy has improved, but that the cut could still impact WIC’s administrative capacity and ability to serve hard-to-reach areas, such as rural communities.

“At this point, do anything,” said Holubowich, calling on public health workers and advocates to speak out and oppose the budget cuts. “This is happening, this is not a drill.”

To read Trump’s 2018 federal budget proposal in full, visit [www.whitehouse.gov](http://www.whitehouse.gov).

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