President’s proposed budget disastrous for public health: Prevention, ACA progress threatened
===============================================================================================

* Lindsey Wahowiak

Public health advocates have called President Donald Trump’s proposed budget for 2019 an assault on health care and devastating to vital public health programs. The proposal is so disastrous and “deeply flawed,” Congress should reject it immediately, according to APHA.

The budget, released Feb. 12 by the White House Office of Management and Budget, outlines the Trump administration’s proposed spending for the upcoming fiscal year. In it, there are extreme cuts to critical public health programs and services.

APHA noted in a Feb. 13 news release that “this request falls in line with the administration’s refusal, since its first day, to adequately fund and protect important health programs and the health of people living in the U.S.”

The proposal fails to fund the $900 million mandatory Prevention and Public Health Fund in fiscal year 2019, a crucial source of funding for many public health programs. It would also greatly reduce funding for Medicaid and Medicare, including reducing Medicaid spending to pre-Affordable Care Act levels, and repeal the ACA.

“Public health agencies have already been operating on shoestring budgets for years, and more cuts will only weaken our nation’s ability to respond to existing and emerging threats to our health,” said Georges Benjamin, MD, executive director of APHA.

Agencies and programs based on science and health take a major hit in the budget. The U.S. Department of Health and Human Services would see a $17.9 billion cut, or 21 percent decrease from 2017 funding levels. APHA noted that the cuts include reducing or eliminating funding for Centers for Disease Control and Prevention programs that address environmental health, birth defects and occupational health and safety. CDC also funds many local health department initiatives, and communities across the country will feel the blow, said National Association of County and City Health Officials interim executive director and chief of government affairs Laura Hanen, MPP, in a Feb. 12 news release.

“The disinvestment in public health programs will only cost this nation more in the end,” Hanen said. “The budget makes deep cuts that will negatively impact CDC and state and local health departments’ ability to do their job — which is to keep our communities healthy and safe.”

The proposed budget would eliminate programs at the Health Resources and Services Administration as well, such as the Ryan White HIV/AIDS Program’s Special Projects of National Significance, which advance innovative service delivery models for challenges that include treating patients co-infected with HIV and hepatitis C and integrating medication for addiction treatment into HIV clinics, said HIV Medicine Association Chair Melanie Thompson, MD, in a Feb. 13 statement. It would also eliminate funding for the HRSA-supported AIDS Education and Training Centers. These programs, Thompson said, are “critical for building and maintaining HIV medical provider capacity at a time when we already lack (a) sufficient…workforce to care for the increasing numbers of persons living with HIV.”

The proposed budget also slashes HRSA programs that provide maternal and child health services, rural health services and training programs that strengthen the health care workforce, APHA noted.

The U.S. Environmental Protection Agency would see a 33.7 percent cut, with just $5.4 billion allocated for the coming year.

Medicare would see a 7.1 percent cut by 2028, and Medicaid would see a 22.5 percent cut in the same timeframe, should the ACA be repealed. Such measures would threaten gains that have already begun to erode under Trump.

While ACA enrollment was strong this year, totals dropped 3.7 percent. Uninsurance rates also increased in 2017 for the first time in four years.

The Trump budget plan also calls for a $17 billion cut in 2019 to the Supplemental Nutrition Assistance Program, colloquially known as food stamps. Much of that cut would come from replacing the current program that offers cash value on debit cards to be used at grocery stores with a monthly boxed delivery of foods, which OMB director Mick Mulvaney described as “Blue Apron-style,” referencing the meal kit service.

However, where Blue Apron boxes average near $10 per serving, SNAP meal cost averages are about $1.40 per serving. All households receiving $90 or more each month from SNAP would see their benefits reduced by half and put into the boxed food delivery. The cuts would affect 34 million people in 16 million U.S. homes in 2019, according to Stacy Dean, vice president for food assistance policy at the Center on Budget and Policy Priorities. The cuts also eliminate SNAP funding for nutrition education.

The president’s budget proposal calls for $13 billion to be spent to combat the U.S. opioid crisis. However, public health advocates described such an investment as drops in the bucket, which are negated by cuts to so many other health programs that people with opioid addiction and others may also need.

“American life expectancy has already declined two years in a row,” Benjamin said. “The administration is well aware of the health challenges our country is scrambling to meet. The priorities outlined in this budget are dismissive of those challenges and are an intentional attempt to kick the can down the road on addressing climate change, preventing chronic disease, stopping infectious diseases including influenza and building a public health infrastructure that can last. We can pay to prevent these problems now, or we can pay tenfold to clean up their harms in the future.”

Trump’s budget proposal was presented to Congress, which will draft its own budget, taking into consideration the president’s requests. Fiscal year 2019 begins Oct. 1. However, the Pew Research Center noted that since the current budget process was put in place more than 40 years ago, Congress has passed all its required appropriations measures on time only four times.

Instead, to keep the U.S. afloat, Congress has passed continuing resolutions, appropriations that maintain or cut current funding levels on an interim basis. Continuing resolutions can harm public health, as they are often stopgap measures at best, said Benjamin, who described Congress’ February continuing resolution as “robbing Peter to pay Paul.”

“We know that every dollar invested in public health returns $5.60 in value through immunizations, disease prevention and by building stronger communities,” he added.

To take action on public health, including calling for protection of the ACA and joining APHA’s Speak for Health campaign, visit [www.apha.org/advocacy](http://www.apha.org/advocacy).

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