We’re hearing a lot about the 22 million people who may lose their health insurance if the Affordable Care Act is repealed. But there’s another, quieter tragedy that could play out if the ACA is gutted: States could lose critical funding for public-health efforts like responding to outbreaks, vaccination programs, and anti-smoking and anti-obesity campaigns.
When the ACA was enacted in 2010, the law established the Prevention and Public Health Fund, with an annual appropriation that began at $500 million in 2010. The goal of the fund was simple: boost public-health funding, much of it for the US Centers for Disease Control and Prevention (CDC), to support activities that prevent people from getting sick. (At a time when more Americans would be gaining insurance, keeping people healthy and out of the health care system carried extra appeal for lawmakers.)
But over the years, the fund has been subject to a slew of cuts. It’s been a prime target for Republicans, who have called it “a slush fund for jungle gyms.” The House Reconciliation Bill, led by Trump’s HHS pick Tom Price, promised to terminate the fund. (The bill passed in the Senate but was vetoed by President Barack Obama.) If the Affordable Care Act is repealed, the fund will most certainly go away — and with it, $890 million of the CDC’s annual budget. Within the next five years, states will lose more than $3 billion, according to a new analysis by the Trust for America’s Health.
“The unintended consequence of the elimination of the Affordable Care Act could be the elimination of 12 percent of CDC’s budget,” said John Auerbach, the president and CEO of Trust for America’s Health and former associate director for policy at the CDC.
Not every state will be impacted in the same way. Some of the preventive-health funding is population-based and some of it is grant based, though the Trust for America’s Health said the biggest states tend to be hardest hit because they have more municipalities that can receive grants.
Removing the funding will mean less money for responses to outbreaks, less money to fight the opioid epidemic, less money to fight superbugs in hospitals, and less money for vaccination programs. It’ll also mean more scrambling for cash at already cash-strapped public health offices. “The indirect impact of the ACA repeal,” Auerbach added, “is that the funding has to come from somewhere else.”
Here’s what that looks like at the state level
Public health departments have always struggled to wrangle enough cash. Unlike health care providers, public health officials work on preventing illness and injury. They devise plans to prepare for those increasingly frequent pandemic threats, like Ebola and Zika, and regulate tobacco use to give us smoke-free environments.
The work isn’t sexy and prevention isn’t newsworthy. Compared to health care — drugs, doctors, and hospitals to keep us alive when we’re sick — public health gets a tiny portion of the health spending pie. As of 2012, only 3 percent of the health budget went to public health measures, the rest mostly to personal health care.
More cuts will be felt deeply, health officials on the ground told me. In Texas, as Zika made its way to America and Congress squabbled over funding the fight against the virus last year, Dr. Umair Shah — the head of public health for Harris County, Texas — had to scramble to find money to pay for his department’s Zika response.
Some of that cobbled-together cash — to spray for mosquitoes, raise awareness about the virus in his community, and test and track the virus — came from the Prevention and Public Health Fund. “As a public health system in this nation, we are under-funded,” Shah said. “We’ve made some progress in funding — with this increase in dollars — and now we have that real concern that it’s going backward.”
In Louisiana, a state with some of the worst health outcomes in America and a massive deficit, it’ll further knock down an already struggling public-health system, said Dr. David Holcombe, who looks after public health for central Louisiana. “We have employees who are [paid through the fund] to do immunizations, STD prevention,” he explained. “In Louisiana, we are number one in syphilis, number one in gonorrhea, number two in chlamydia, and number two in HIV/AIDS. It’s hard to imagine how we could get worse in all this stuff.”
Public health already gets a tiny portion of the health funding pie
There are a few reasons why public health is so chronically under-funded. In a 2010 op-ed the New England Journal of Medicine, Harvard’s David Hemenway explained that our brains are wired to focus on short-term issues, which deliver more immediate rewards, instead of long-term challenges, like public health. "Since it takes willpower to delay gratification, individually and collectively we sometimes underinvest in the future," he wrote.
Whether its improving road safety, preventing a pandemic, or limiting the effects of climate change — all of which fall under the remit of public health — they "incur costs today but don't provide benefits until sometime in the future." Not exactly a politically palatable option.
When public health works, it’s often invisible. When we have mosquito-control programs that prevent Zika from spreading, it’s a non-story. When we aren’t poisoned by our food, it’s a non-story. It’s also more difficult to talk about the benefits of public health: They tend to be long term, slow to show up, and affect entire populations instead of individuals. "Public health has little news value — saving statistical lives doesn't make for good human-interest stories or photo ops," Hemenway writes.
Cutting the public-health funding any further, the outgoing CDC director, Tom Frieden, told Vox in an interview, “would [lead to] tens of thousands of additional illnesses and more than 10,000 additional deaths.”
At a time when life expectancy in the US has declined for the first time in decades, nearly half the population is overweight or obese, and deaths from opioids have more than quadrupled in just 15 years — we could use more public health efforts to prevent these things for happening in the first place. Instead, we may be moving in the opposite direction.
In Trump’s health care reform position statement, he said, “The best social program has always been a job — and taking care of our economy will go a long way towards reducing our dependence on public health programs.” It’s not clear how job creation would stop an Ebola outbreak, or control tobacco, or test people for STDs. But we will soon find out.