President’s budget would hinder US public health progress: Huge cuts proposed
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* Kim Krisberg

White House budget proposals are often more vision than reality. But they offer revealing insights into an administration’s values and priorities. Unfortunately, in the case of President Donald Trump’s new budget plan, many of those priorities are out of step with public health, proposing significant cuts to vital programs and agencies.

“In a time where life expectancy is falling, our leadership should be investing in better health, not cutting federal health budgets,” said APHA Executive Director Georges Benjamin, MD, in a news release. “This budget, put simply, kicks the can of worsening American health down the road.”

Trump released his fiscal year 2020 federal budget proposal in March, recommending huge cuts across the federal government, including a 12 percent cut to the U.S. Department of Health and Human Services and a 10 percent cut for the Centers for Disease Control and Prevention.

At CDC, a reduction of that magnitude equates to a $750 million spending cut over fiscal year 2019. APHA member John Auerbach, MBA, president and CEO of Trust for America’s Health, said the proposed CDC cuts not only threaten federal public health capacity, they would have a “devastating” impact on state and local public health departments, which depend heavily on CDC dollars flowing down to the community level.

“Local health departments are still down more than 50,000 jobs from where they were in 2008,” Auerbach told *The Nation’s Health.* “If large cuts like these were passed, it would seriously harm the overall capacity of state and local public health departments to respond.”

Among its proposals for CDC, the White House budget calls for a more than $236 million cut to chronic disease prevention and health promotion, a $146 million cut for the National Institute for Occupational Safety and Health, a more than $102 million cut to emerging and zoonotic diseases, and about a $52 million cut to CDC’s environmental health activities, including funding for asthma and childhood lead poisoning.

The budget proposes a near $20 million cut to injury prevention and control, a more than $30 million cut to public health preparedness and response, and a more than $78 million cut to immunization activities, including work to sustain and improve immunization coverage. The budget also zeros out critical funding for epidemiology and laboratory capacity at state and local levels.

On the flip side, the Trump budget proposes an additional $140 million to support a new plan to end U.S. HIV transmission by 2030. It also calls for an additional $53 million to address the opioid and related disease epidemic, nearly $50 million more for global health security and $10 million more for modernizing flu vaccines.

More funding for serious challenges such as HIV and opioid addiction is good news, said Adriane Casalotti, MPH, MSW, chief of government and public affairs at the National Association of County and City Health Officials. But the budget’s siloed approach to such problems also suggests a misunderstanding of the complexity of disease prevention and control.

“There are certain, basic fundamentals that should be in place everywhere,” she told *The Nation’s Health.* “No matter what ZIP code you live in, people should know there’s a strong public health system there to support them.”

For example, Casalotti said, the White House budget proposes a $585 million increase for the Vaccines for Children Program, which provides free immunizations to children who might otherwise go unvaccinated. At the same time, however, the budget proposes significant funding cuts to CDC work that sustains protective immunization levels, such as activities to address vaccine hesitancy and gather data on at-risk populations. The White House efforts on HIV and opioid addiction have come under similar criticism — especially considering that Trump’s budget calls for massive cuts to Medicaid, a critical provider of addiction and HIV care.

“It’s definitely good to have HIV recognized at the highest levels for the epidemic that it is,” Melanie Thompson, MD, immediate past chair of the HIV Medicine Association, told *The Nation’s Health.* “Any new money that’s allocated is going in the right direction, but it’s a drop in the bucket in terms of what we really need to end the epidemic.”

Thompson, also a principal investigator at the AIDS Research Consortium of Atlanta, said that because the HIV epidemic overlaps so profoundly with social determinants of health such as poverty, housing and access to affordable care, it is hard to envision meeting the goal of ending HIV transmission by 2030 if Trump’s proposals to slash the social safety net also came to fruition.

Ending the U.S. HIV epidemic also requires action to stop the virus globally, Thompson said, noting that the White House budget calls for a 29 percent cut to the President’s Emergency Plan for AIDS Relief, which has provided millions with lifesaving treatment.

“We’re not in a position to turn down any money that could help us focus energy on ending this epidemic,” she said. “But you can’t give with one hand and take with the other.”

On programs that impact many social determinants of health, Trump’s budget proposes more huge reductions, including a $777 billion cut to Medicaid over 10 years, as well as nearly $600 billion in net Medicare spending reductions. According to the Center on Budget and Policy Priorities, Trump’s 2020 budget would cut Social Security assistance for people with disabilities, cut billions from Temporary Assistance for Needy Families, raise the rent for low-income households receiving housing assistance, and cut the Supplemental Nutrition Assistance Program by $220 billion over the next decade.

Other public health-related agencies under the ax in the White House budget include a 31 percent reduction at the Environmental Protection Agency, an 18 percent cut for the U.S. Department of Housing and Urban Development, and a 15 percent cut to the U.S. Department of Agriculture.

The budget proposes a $1 billion cut to the Health Resources and Services Administration, a $4.7 billion cut to the National Institutes of Health, including a nearly $900 million cut for the National Cancer Institute, and a cut of $65 million at the Substance Abuse and Mental Health Services Administration. The budget proposes a small increase for the Occupational Safety and Health Administration, as well as funding for more full-time OSHA employees.

“It is surprising to see cuts that were reverse sides of the coins we know the administration cares about,” said Dara Lieberman, MPP, director of government relations at Trust for America’s Health, citing proposals such as increasing opioid funding at CDC, while decreasing funding for suicide and substance abuse at SAMHSA. “Putting your thumb over one break in the dam while allowing other breaks to grow doesn’t work.”

While a presidential budget proposal is by no means a done deal, it does factor into overall decision-making by legislators, said Emily Holubowich, MPP, executive director of the Coalition for Health Funding, of which APHA is a member.

Holubowich called on public health supporters to urge lawmakers to adequately fund public health during budget negotiations. She said the new 22 by 22 campaign, an initiative of the Association of State and Territorial Health Officials that calls for increasing CDC funding by 22 percent by fiscal year 2022, is a good starting point.

“Policymakers listen to the public,” Holubowich told *The Nation’s Health.* “If they’re not hearing from constituents that CDC matters, they’re not going to fund it. That’s why it’s important to take the president’s budget seriously and communicate why cuts are bad for public health. We need to talk to anyone who will listen about why public health matters.”

To take action on public health funding, visit [www.apha.org/policies-and-advocacy](http://www.apha.org/policies-and-advocacy). To read the budget proposal, visit [www.omb.gov/budget](http://www.omb.gov/budget).

*Editor’s note: This article was corrected post-publication.*

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