New administration raises worries about public health: ACA, climate change, gains under threat
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* Kim Krisberg

As a new president and Congress settle into office, many advocates are doing what front-line public health workers do every day: hoping for the best while preparing for the worst.

Work under President Donald Trump and the new Congress has just begun, but advocates say that based on statements during the presidential campaign, the histories of people chosen to serve in Trump’s cabinet and backgrounds of new congressional leaders, core public health activities and priorities likely face a challenging future.

The most imminent threat to America’s health under the new administration are attacks on the Affordable Care Act and a reversal of historic gains in insurance coverage. But in addition to insurance losses, the strategy that opponents are using to repeal the ACA — a budgetary process that targets spending and revenue associated with the law — could also mean elimination of the Prevention and Public Health Fund. Created under the ACA, the vital fund provides almost $900 million annually to the Centers for Disease Control and Prevention and has become entwined with CDC’s base budget, said Emily Holubowich, MPP, executive director of the Coalition for Health Funding and an APHA member. 

![Figure1](http://www.thenationshealth.org/https://www.thenationshealth.org/content/nathealth/47/1/1.3/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/47/1/1.3/F1)

Brenda Major, left, receives a checkup from Fernanda Mercade, MD, at a community health clinic in Miami in 2012. Major has a pre-existing condition that would have made it hard to find insurance before the Affordable Care Act took effect. The ACA is targeted for repeal under the new Congress.

Photo by Joe Raedle, courtesy Getty Images

“The best-case scenario for CDC and public health funding, at large, is flat funding,” Holubowich, who is also a senior vice president at CRD Associates, told *The Nation’s Health*. “I think (leaders) in Congress and in the administration are intent on decreasing available funding for nondefense discretionary funding. In fact, taking our cues from people who may be in key positions on what they’ve introduced before, sequestration may end up being the high-water mark.”

While the Prevention and Public Health Fund was intended as additional funding, its monies have increasingly been used to backfill budget shortfalls. That means if the fund is repealed, the ramifications would be felt in core public health activities. For example, Holubowich said, the fund is now supporting CDC’s 317 immunization grant program, a main source of funding for state and local vaccination efforts. It also supports epidemiology and public health lab capacity and represents the only source of funding for the Preventive Health and Health Services Block Grant, which state health agencies use to address a range of local issues, from emergency response to chronic disease.

The fund already lost some of its funding in December, when billions of dollars were diverted to pay for the 21st Century Cures Act. Eliminating the fund overall would leave CDC facing a 12 percent reduction in its budget, Holubowich said, noting that the fund’s repeal may force lawmakers to raid other public health programs to make up the loss of funds.

At the local level, where CDC funds are a critical source of support, repealing the prevention fund would be “devastating,” said LaMar Hasbrouck, MD, MPH, executive director of the National Association of County and City Health Officials. Hasbrouck said he is also concerned that attacks on the ACA could disrupt ongoing work to create better linkages between public health and health care sectors — work that is often financially incentivized via the ACA with a goal of producing better health outcomes for patients and lowering health care costs.

For example, NACCHO’s “Strengthening America’s Health and Safety by Partnering with Local Health Departments: Recommendations for the Next President and the 115th U.S. Congress,” released in December, noted that the ACA established a spectrum of payment models that encourage health care systems to reach out to nonclinical partners and address population health.

“It’s absolutely critical to makes these linkages between health care and public health,” Hasbrouck told *The Nation’s Health.* “Really, it’s a sweet spot for public health, and a win-win for everyone involved.”

Beyond ACA-related issues, Hasbrouck called for “sustained funding” for planning, preparedness and surge capacity, noting that the Zika and Ebola outbreaks highlighted how “cumbersome” it can be to get resources through Congress. NACCHO is also calling on the new administration to support local public health as “chief community health strategists,” which is in line with the U.S. Department of Health and Human Services’ new Public Health 3.0 vision. APHA member Chrissie Juliano, MPP, director of the Big Cities Health Coalition, whose health agencies serve 1 in every 6 Americans, echoed many of Hasbrouck’s hopes and concerns.

Juliano said metropolitan health departments face serious health threats that require federal attention. Such agencies are on the front of the opioid abuse and overdose epidemic, which took the lives of 33,000 Americans in 2015. In December, President Barack Obama signed the 21st Century Cures Act, which provides $1 billion to help states address opioid treatment. But no money has been appropriated for prevention. Juliano said that Trump talked about opioid addiction during his campaign, so “we’re hopeful that we can work with him on that.”

Overall, Juliano, like other advocates, is bracing for shrinking public health resources.

“(Trump) has talked about a hiring freeze, but he did make an exception for public health,” Juliano told *The Nation’s Health*, referring to November reports that Trump would institute a hiring freeze for civilian federal jobs that do not involve public safety or public health. “So I’m hopeful that he understands the needs of this sector.”

## Health coverage for millions now at risk

With an ACA repeal at the top of Congress’ agenda, loss of insurance among the 20 million Americans who gained coverage thanks to the law is at the forefront of health policy discussions.

According to research from the Urban Institute released in December, the budgetary process lawmakers are using to repeal the ACA would mean the number of uninsured people would rise from 28.9 million to more than 58 million in 2019. Of those newly uninsured, more than 22 million would lose coverage due to the elimination of premium tax credits, Medicaid expansion and the coverage mandate. The great majority of people who would lose coverage — 82 percent — live in working families.

However, Ron Pollack, JD, executive director of Families USA, noted that it is far easier to talk about repealing the ACA than to actually do it. For instance, he said, keeping popular ACA provisions that bar discrimination based on pre-existing conditions is only sustainable through balanced insurance pools that also include younger, healthier people. Without such balanced pools, Pollack said, premiums will skyrocket, putting coverage financially out of reach for many with pre-existing conditions. An ACA repeal would also affect those with employer-provided insurance.

“It means people who now have health coverage through their jobs will no longer have the flexibility to change their circumstances,” Pollack told *The Nation’s Health*. “A key purpose of the ACA was to make sure that irrespective of job circumstances or income, you would have access to affordable coverage, and that will no longer exist.”

Coverage through Medicaid and the Children’s Health Insurance Program is also at risk in the coming year, said Bruce Lesley, president of First Focus, a children’s advocacy group. Though CHIP is authorized through 2019, its funding expires in September. Ideally, Congress should provide support CHIP funding as soon as possible, as states are creating budgets now and need to know how much federal funding is on the horizon. But Lesley is worried that with so much focus on the ACA, “CHIP is off the radar.”

Lesley also said that proposals to block grant federal Medicaid funding and merge CHIP into Medicaid — an idea previously introduced by HHS secretary nominee Rep. Tom Price, R-Ga. — would leave kids competing with a growing senior population in need of long-term and nursing home care, both of which Medicaid currently covers. And because children can’t vote, Lesley predicts “children would be the big losers.” As of 2015, CHIP covered more than 8 million low-income kids.

“We’re worried that CHIP will be an afterthought; we’re worried that kids’ angles to all of this will be neglected,” he said.

The future of women’s health has advocates worried as well. In fact, APHA member Gretchen Borchelt, JD, vice president for reproductive rights and health at the National Women’s Law Center, said “everything is on the line with this new administration.”

On the ACA, Borchelt said while the budgetary repeal process does not target specific benefits, such as contraception coverage, the new administration could still act to restrict birth control access. For instance, she said the Trump administration could stop defending contraception coverage in the courts against attempts to carve out coverage exceptions for those who oppose birth control on religious grounds. The administration could also attempt to re-write the parameters of how ACA benefits operate, she noted. Regarding ideas to block grant Medicaid, she said the effort — which advocates predict will result in a roll back of benefits at the state level — would disproportionately affect low-income women.

On abortion, Borchelt said to expect an “onslaught” of attempts in Congress and in the states to restrict access.

Advocates are also concerned about potential regulatory rollbacks, from worker health protections to nutrition upgrades. One example is the healthier school meal standards signed into law in 2010, which most schools have adopted and research shows is motivating kids to eat more fruits and vegetables. APHA member Michael Jacobson, PhD, executive director of the Center for Science in the Public Interest, said Congress has the power to repeal the school meal standards, adding that he believes the signature law will be a target.

Jessica Martinez, MPH, co-executive director of the National Council for Occupational Safety and Health, is similarly worried about regulatory changes, adding that cues at the federal level make local mobilization important.

“Cutting back on safety protections does not save money or make it easier to do business,” Martinez said. “For us, worker health and safety should be considered a nonpartisan issue.”

Another top public health priority in the coming year is climate change. APHA member Kim Knowlton, DrPH, MS, senior scientist and deputy director of the Science Center at the Natural Resources Defense Council, noted that CDC’s Climate-Ready States and Cities Initiative already covers half the U.S. population and it would make sense to expand it so all communities are prepared to meet the challenges of a changing climate. She is cautiously optimistic that lawmakers will see the human and economic value of readying for climate change. APHA has declared 2017 the Year of Climate Change and Health and is rallying its members.

To take action on public health issues that are under threat, visit [www.apha.org/advocacy](http://www.apha.org/advocacy).

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