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The US is about to make the same pandemic preparedness mistakes — again

Democrats’ plans for public health funding fall far short of what experts say is necessary.

The Build Back Better legislation totals about $10 billion in public health infrastructure and pandemic preparedness funding over the next few years.
Bill Clark/CQ-Roll Call/Getty Images
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

Public health officials and outside experts warned the federal government for years before the coronavirus pandemic that the US was not focusing enough on public health prevention. They were proven right. Now they are again pleading with the federal government to invest more money into preparedness, to take a lesson from Covid-19 about what happens when we don’t prioritize those programs.

But the country is in danger of repeating the same mistakes. Advocates expected a smaller investment in preparedness as part of the forthcoming Build Back Better Act than they believe is necessary. Outside experts have estimated that as much as $75 billion should be spent over 10 years on public health infrastructure, preparedness, and prevention.

The revised Build Back Better legislation totals roughly $10 billion in public health infrastructure and pandemic preparedness funding over the next few years — a down payment on better readiness, in Democrats’ view, but one without assurance of future installations.

“All too often, when there’s a crisis, the reaction is to put money into public health. Once the crisis subsides, the funding tends to dry up,” Ron Bialek, president of the Public Health Foundation, told me. “This is not a recipe for success.”

There is additional funding in the bill to expand the medical workforce, a need experts and hospital leaders also say the pandemic has made impossible to ignore.

It’s difficult to say exactly how the last 18 months could have gone differently if more funding had been spent on preparing. But the country would have likely had more funding for health care workers, more support for disease surveillance and data-sharing systems, and more emphasis on preventing the chronic health conditions that make the virus more deadly.

Experts inside and outside government are urging Congress to approve new, sustained funding for public health programs. Congress has approved temporary funding throughout the pandemic, but public health officials and advocacy groups want dedicated annual funding streams — the kind of resources they say are necessary to prevent a repeat of the US’s Covid-19 failures when the next deadly pathogen breaks through.

“It’s difficult at the local and state level to make long-term decisions about setting up infrastructure and hiring people when you don’t know if the money is going to run out,” Anand Parekh, chief medical adviser at the Bipartisan Policy Center, told me.

Several proposals attempt to estimate how much sustained funding is needed. The Bipartisan Policy Center included in its list of recommendations $7.6 billion in new annual funding, or $76 billion over 10 years once the funding is fully phased in. Trust for America’s Health has called for at least $4.5 billion annually ($45 billion over a decade) in public health infrastructure funding. The Biden White House laid out its own 10-year pandemic preparedness proposal, which a senior official likened to the Apollo moon missions, that requires $65 billion in total.

The Biden White House had originally asked Congress to make a $30 billion down payment on pandemic preparedness as part of its infrastructure plan.

But cognizant that it may be difficult to secure that much money in this reconciliation bill, given centrist Democrats’ concerns about the legislation’s overall cost, the White House lowered its request to $15 billion, which the House reconciliation bill, as currently written, would roughly meet.

And so, with centrists pressuring Democratic leaders to keep the bill’s costs down, Congress is preparing to pass a bill with a fraction of the funding experts say is necessary to prepare for the next pandemic, in what may be the last major legislation of this Congress. While more money could in theory pass later, public health experts worry an opportunity is being squandered.

How public health funding can help fight pandemics

Public health preparedness covers a lot of different things — all of which have been relevant to the fight against Covid-19.

Under the White House’s broader 10-year plan, the first priority would be enabling the rapid development of new vaccines and therapeutics when a threatening pathogen emerges.

It called for half of the $65 billion total cost to be spent on those biomedical pursuits, with the goal of producing enough vaccines for the entire US population within 130 days of a new infectious disease being identified and enough for the whole world within 200 days. Operation Warp Speed was one of the most effective parts of America’s Covid-19 response by supporting vaccine development, and the goal of the White House plan is to accelerate the timeline even more with sustained preparedness funding.

Both the Bipartisan Policy Center and Trust for America’s Health also recommended Congress create a permanent public health “infrastructure” fund. Those dollars could be spent on hiring staff, as well as building and maintaining the systems necessary to surveil infectious diseases and communicate with the public.

“We’ve seen how important it is to get timely and accurate data,” Philip Huang, director of the Dallas County, Texas, health department, told me.

In his county, Huang said they want to invest in data systems that would allow the speedy dissemination of information. He pointed out that, at their mass vaccination sites, staff were still forced to take paper vaccine cards and enter the information manually into a digital database. Dallas County has also relied on online vendors to communicate virtually with its constituents, sending them text messages and other important alerts.

Better data-sharing and better communications are two ways the US could improve its pandemic response. But that would require the money to, for example, renew the licenses for some of those online services.

“Historically, people have short memories after these things. People put a little money into supporting infrastructure, but in between, they forget and that’s one of the first things that gets cut,” Huang said. “This should hopefully once and for all show we need to be investing in this stuff.”

Lastly, preparedness means investing in public health prevention programs that actually improve the health of the population before a deadly virus or bacteria ever arrives. Poor health across the United States was another contributor to America’s struggles during the pandemic.

According to one study published earlier this year in the Journal of the American Heart Association, about two-thirds of all Covid hospitalizations in the US through mid-November 2020 were attributable to one of four health conditions: diabetes, obesity, hypertension, and heart failure. About one in 10 Americans have diabetes, about four in 10 are obese, and nearly half of adults have hypertension. These are chronic, widespread problems that many Americans are struggling with and that make them more vulnerable to certain communicable diseases, including Covid-19.

Public health officials and other experts have a lot of ideas about how to prevent more Americans from developing those conditions and improving the health of the people who already have them — healthy eating initiatives, screening programs, etc. — and they believe more investments in those efforts would pay off the next time a health emergency strikes.

“You really need a resilient population in order to be able to withstand an emergency,” Parekh said. “Much of what we see in the health care setting is preventable. Public health is a set of activities that can prevent a lot downstream of what our health system sees.”

But the problem, as always, is money. The Affordable Care Act actually created a public health prevention fund, but what happened to it after the law’s passage is a microcosm of the whole problem of public health funding.

The prevention fund was supposed to be built up over time. But almost immediately, Congress started taking money from the fund to offset other spending plans. At this point, according to Parekh, the fund was supposed to be up to $2 billion — but there is actually only $900 million in there. The Bipartisan Policy Center’s public health funding plan would increase the prevention fund, on a permanent annual basis, to $4 billion.

The last 18 months suggest the US would have been better off spending that money as originally intended. But the will to invest in public health is always short-lived. In spite of the pleas from the public health community, Congress may again prove to be shortsighted when it comes to public health investments.

“This is the time to prepare for the next one,” Parekh said. “It’s not a question of if, but it’s a question of when we’ll face the next pandemic.”

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