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Trump's budget on health: 3 losers and 2 winners

Pro: a new pandemic response fund and renewed commitments to fight HIV. Con: Health research is crippled.

President Donald Trump’s budget blueprint, out today, includes devastating cuts to health research funding and public health programs — along with some vague commitments to launch a pandemic response fund and maintain funding in the fight against HIV.

While the plan may be too extreme to get Congress’s seal of approval, the White House is signaling a clear desire to gut some of America’s health infrastructure to bolster defense spending and build a wall along the US-Mexico border.

We’ve parsed the health winners and losers in the budget for you. Here’s a quick overview.

Loser: The National Institutes of Health

The 18 percent cut to the Department of Health and Human Services includes a $5.8 billion reduction for the National Institutes of Health, or about a fifth of its budget.

This will decimate the basic and clinical scientific infrastructure in the United States, said Joseph Ross, a professor of medicine at Yale University. Spending on health R&D in the US has already been flagging, and most of the NIH’s budget goes to an army of 300,000 outside researchers, so a very broad community of researchers would feel the effects of a budget reduction of this size.

According to Matt Hourihan, the director of the R&D Budget and Policy Program for the American Association for the Advancement of Science, when the NIH’s budget dropped 5 percent from sequestration cuts, they had to cut around 700 individual grants (out of about 9,000). With a 20 percent cut, “We’re likely talking about [grant] cuts in the hundreds, if not the thousands,” he told Vox’s Brian Resnick.

The cuts would mean less publicly funded science on things like how to treat pain, fight aging, or create vaccines for diseases like Ebola. “Our [research] showed that publicly funded science conducted at academic research institutions and government labs is the source of the most important innovations and products that become transformative therapeutics,” said Aaron Kesselheim, an associate professor of medicine at Harvard Medical School. “Deep cuts like this will turn off the discovery of the important new therapies of tomorrow.”

The budget also calls for “a major reorganization of NIH’s institutes and centers to help focus resources on the highest priority research and training activities.” There’s not much detail on exactly what this reorganization would look like, except that the budget proposes eliminating the Fogarty International Center, a $69.1 million global health program at NIH that funds 400 research and training projects involving more than 100 US universities and other countries.

The center has also been studying the impact of climate change on disease outbreaks, which may be why it’s a target. “We do know that global climate change is very much related to elevated risk of disease,” said John Auerbach, president and CEO of the public health nonprofit the Trust for America’s Health. “There seems to be a pattern [in the administration] of reducing funding for either research or programs that address local climate change.”

Loser: Health services research

The administration also calls for consolidating the Agency for Healthcare Research and Quality within NIH. AHRQ was founded to work within the Department of Health and Human Services, with the mission of producing evidence to make health care safer, higher quality, and more affordable.

AHRQ is hugely important: It’s the only US organization dedicated to studying health delivery, looking at questions like how best to treat back pain among all the potential remedies that are available, or reduce the risk of central line infections so people don’t die while being cared for in hospitals.

Bringing AHRQ into the NIH at a time when the NIH is facing deep cuts might kill it, experts told me.

“The NIH may not value the AHRQ mission,” since it’s comprised mainly of organ and disease-based research institutes, said Victor Montori, professor of medicine at Mayo Clinic and a senior adviser to AHRQ. “Any budget cuts will prioritize preserving NIH core programs.”

AcademyHealth president and CEO Lisa Simpson gave a similar prediction. “If NIH is losing 20 percent of its budget, AHRQ would just disappear.”

Loser: Public and environmental health

Photo of a new water spiget installed at Benton Elementary School in Portland, Oregon. Brianna Soukup/Portland Press Herald via Getty Images

There’s little detail on what the massive cuts at HHS will mean for the Centers for Disease Control and Prevention, the nation’s public health agency, except for a $500 million block grant for states.

Right now, CDC funding is allocated by Congress and distributed to states, local health departments, and nonprofits based on categories of health issues like STDs and heart disease.

The $500 million block grant would loosen those restrictions, but may actually be a disguise for cuts. “What we have seen in the past when block grants are created,” Auerbach said, “they often lump together different previously existing programs and then cut them significantly.”

There are other assaults on public health in this budget. The Trump plan calls for eliminating “programs that are duplicative or have limited impact on public health and well-being.” Again, aside from cutting Fogarty, it isn’t clear what those programs may be. The budget does single out health professions and nursing training programs, though, “which lack evidence that they significantly improve the Nation’s health workforce” and proposes cutting them by $403 million. That might mean a reduction in training capacity for nurses, the nation’s frontline health providers.

Sarah Frostenson

What’s more, there’s dramatic cuts to funding for affordable housing, community development, and environmental health programs in other agencies. The Trump administration proposed a $6 billion, or 13 percent, reduction in the budget for the Department of Housing and Urban Development (HUD).

“We are still in the early stages of understanding the extent of importance of housing as a determinant of health — for example, health hazards in rental homes, neighborhood environments for physical activity, lead exposure, community development, clean water, sidewalks,” said University of Minnesota public health researcher Sarah Gollust. “And all of these would be hugely affected by cuts to HUD.”

The White House would also cut $26 billion from the Environmental Protection Agency — a 31 percent reduction from 2017. This may imperil other important public health programs, including efforts to reduce the risk of lead poisoning and ensure clean drinking water in communities.

In the only mention of women’s health in the budget, Trump would provide $6.2 billion to the WIC program, which helps states meet the nutritional and health needs of low-income pregnant and postpartum women, infants, and children. This represents a $150 million cut from FY 2016 — and the program was already cut by $273 million the year before that.

Winner: Responding to crises like Zika and bird flu

Brazil's Zika Babies Celebrate Their First Christmas
A mother, Raquel Barbosa, sitting with her daughter Eloisa, who who was born with microcephaly after a Zika infection in Brazil.
Photo by Mario Tama/Getty Images

There are some bright spots in the budget when it comes to health, though they come with major caveats.

Researchers and health officials have long been calling for a federal emergency respond fund for public health disasters, similar to FEMA, the Federal Emergency Management Agency.

In public health right now, whenever there's a threat of an infectious disease spiraling out of control, officials and researchers from around the country head to Washington, DC, to plead for emergency money before Congress. The scramble has played out with disturbing regularity — for Ebola, H1N1 (also known as swine flu), and Zika.

The budget seems to address this by creating “a new Federal Emergency Response Fund to rapidly respond to public health outbreaks, such as Zika Virus Disease.”

“This is potentially a good sign,” said Jennifer Kates, director of global health and HIV policy at the Kaiser Family Foundation. “It seems to be a recognition of that call [by the public health community]. But it’s unclear where the funding is coming from.”

The budget doesn’t specify whether it’s a new pot of money, or whether it’s repurposing funds from other things.

Winner: The fight against HIV and malaria

Among the few promises made on health was one to preserve funding for domestic and global HIV programs.

On the domestic front, the budget calls for funding for Ryan White HIV/AIDS providers — a “high priority” it wants to continue. Ryan White programs provide health care to people living with HIV who cannot get health insurance. With $2.3 billion in funding in the last budget, it’s the third-largest source of federal money for domestic HIV care after Medicare and Medicaid.

The budget also “provides sufficient resources to maintain current commitments and all current patient levels on HIV/AIDS treatment under the President’s Emergency Plan for AIDS Relief.”

PEPFAR is America’s global heath program to combat AIDS around the world and the largest commitment by any country dedicated to a single disease. The program funds daily lifesaving antiretroviral treatment for 11.5 million people, which is equal to the population of New York and Chicago.

In addition, the White House would maintain funding for malaria programs and meet the US commitments to the Global Fund, the international global health financing organization.

But the language in the budget blueprint doesn’t attach dollar amounts to these commitments. Those details may come in the final budget proposal, out in May.

More broadly, funding for AIDS and malaria isn’t safe. The protections on these specific disease programs comes amid the deep cuts to NIH, as well as the 30 percent cuts to the State Department, and USAID — agencies that are also key players on helping battle infectious diseases like HIV and malaria. The budget also decreases funding for the UN system, which could hit the World Health Organization. So even the apparent winners in this budget on health may not be winners after all.

Maybe a winner? Maybe not. The opioid epidemic

The budget includes “a $500 million increase above 2016 enacted levels to expand opioid misuse prevention efforts and to increase access to treatment and recovery services to help Americans who are misusing opioids get the help they need.” At a glance, this seems like Trump is making good on his pledge to “expand treatment for those who have become so badly addicted.”

But as Vox’s German Lopez explains, there’s good reason to think that money may not be new at all. “The $500 million being referred to might not be funding that Trump initiated at all. Instead, it very well could be an allocation of spending that Congress and President Barack Obama already approved in the past year as part of the 21st Century Cures Act. That law put forward $1 billion over two years — $500 million in the current fiscal year (2017) and $500 million in the next fiscal year (2018).”

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