The Impact of ISSUE REPORT Chronic Underfunding on America’s Public Health System: Trends, Risks, and Recommendations, 2019 APRIL 2019 Acknowledgements Trust for America’s Health (TFAH) is a nonprofit, nonpartisan public health policy, research, and advocacy organization that promotes optimal health for every person and community and makes the prevention of illness and injury a national priority. This report was supported by the Robert Wood Johnson Foundation and W. K. Kellogg Foundation. Opinions in it are TFAH’s and do not necessarily reflect the views of either foundation. TFAH BOARD OF DIRECTORS Gail Christopher, DN Theodore Spencer Karen Remley, MD, MBA, MPH, FAAP Chair of the Board Secretary of the TFAH Board & Senior Fellow President and Founder, Ntianu Center for Founding Board Member De Beaumont Foundation Healing and Nature Former CEO and Executive Vice President Stephanie Mayfield Gibson, MD Former Senior Advisor and Vice President, W.K. American Academy of Pediatrics Senior Physician Advisor and Population Health Kellogg Foundation Consultant John A. Rich, MD, MPH Cynthia M. Harris, PhD, DABT Former Senior Vice President Population Health Co-Director of the Center for Nonviolence and Vice Chair of the Board and CMO Social Justice Director and Professor KentuckyOne Health Drexel University School of Public Health Institute of Public Health David Lakey, MD Eduardo Sanchez, MD, MPH Florida A&M University Chief Medical Officer and Vice Chancellor for Chief Medical Officer for Prevention and Chief David Fleming, MD Health Affairs of the Center for Health Metrics & Evaluation Vice Chair of the Board The University of Texas System American Heart Association Vice President of Global Health Programs Octavio Martinez, Jr., MD, DPH, MBA, FAPA Umair A. Shah, MD, MPH PATH Executive Director Executive Director Robert T. Harris, MD Hogg Foundation for Mental Health Harris County (Tx) Public Health Treasurer of the Board The University of Texas at Austin Vincente Ventimiglia, JD Senior Medical Director Chairman, Board of Managers General Dynamics Information Technology Leavitt Partners REPORT AUTHORS CONTRIBUTORS PEER REVIEWER Matt McKillop, MPP This report benefited from the insights and Dara Alpert Lieberman, MPP Senior Health Policy Researcher and Analyst expertise of the following external reviewer. Director of Government Relations Although the reviewer has reviewed the Vinu Ilakkuvan, DrPH Daphne Delgado, MPH report, neither the reviewer nor the reviewer’s Consultant Senior Government Relations Manager organization necessarily endorse its findings or conclusions. Zarah Ghiasuddin TFAH Intern Donald Hoppert Director of Government Relations American Public Health Association 2 TFAH • tfah.org Introduction introduction INTRODUCTION The United States has made enormous strides in improving population health and longevity,1 but significant challenges remain. More than a third of adults, and nearly one in five children, have obesity,2 costing the nation hundreds of millions in related health care expenses.3 Tobacco use is still the leading cause of preventable death.4 Risks from infectious disease, drug-resistant superbugs, and foodborne illness continue to pose a challenge. A rapid rise in deaths from drugs, alcohol, and suicide represent an urgent crisis.5 Weather- related emergencies are becoming more frequent and intense, as the world begins to feel the effects of climate change.6 And across most health outcomes, socioeconomic, racial, and ethnic disparities persist.7 Tackling these issues requires a strong, well- This annual report examines federal, state, and resourced public health system focused on local public health funding, and it recommends prevention, preparedness, wellness, and investments and policy actions needed to prioritize community recovery for all Americans. But prevention, effectively address 21st century threats, chronic underfunding has presented a consistent and ultimately achieve optimal health for all obstacle. In 2017, public health represented just Americans. With chronic underfunding putting 2.5 percent—$274 per person—of all health lives at risk, the stakes are rising. spending in the country.8 Such underfunding flouts overwhelming evidence of the life-saving cost-effectiveness of programs Figure 1: Voters Broadly Support Public Health that prevent diseases and injuries and prepare for Protections and Investments disasters and health emergencies. Public health interventions, such as childhood vaccinations,9 school-based violence prevention programs, and indoor smoking bans, improve health outcomes and prevent illness and death.10 Moreover, many 89% such interventions save money; a 2017 systematic review of the return on investment of public health interventions in high-income countries found a median return of 14 to 1.11 of voters believe public health plays an important role In an age of widening political polarization, public in the health of their health programs enjoy broad support. A September community. 2018 poll of U.S. voters found that 89 percent of respondents believed that public health plays an important role in the health of their community. A majority of voters (57 percent) were willing to pay higher taxes to ensure that everyone has access to Source: The De Beaumont Foundation APRIL 2019 basic public health protections.12 (See Figure 1.) 3 1 Federal Public Health Funding SECTION 1: Federal Public Health Funding Federal dollars support a wide range of essential public health programs that aim to improve health, prevent diseases and injuries, and prepare for potential disasters and major health emergencies. Much of this money flows through the Centers for Disease Control and Prevention (CDC), with additional funds going to other agencies within the U.S. Department of Health and Human Services (HHS), as well as the United States Department of Agriculture (USDA). CDC funding trends emergencies, have not made up for resources The CDC is the nation’s leading public health lost in earlier years, let alone emerging threats.17 agency. Its mission is to protect Americans Finally, the CDC also lacks sufficient dedicated from disease outbreaks, disasters, and unsafe funding to adequately support the cross-cutting, food and water, and to reduce the incidence foundational capabilities that form the backbone of leading causes of Americans’ deaths. To of comprehensive public health systems at the help accomplish its objectives, the CDC federal, state, and local levels.18 supports states, localities, tribes, territories, Fiscal Year (FY) 2019 program funding for the and community organizations in addressing CDC, as enacted in September 2018, is $7.3 leading health threats in their communities. billion.19 (See Figure 2.) After accounting for Indeed, more than half of its program funding interagency transfers and one-time funding,* this is redistributed to these partners.13 reflects a $143 million (2 percent) increase over The agency’s budget has not kept pace with FY 2018—or flat funding in inflation-adjusted the nation’s growing public health needs and dollars. emerging threats, particularly the rise in substance The CDC’s FY 2018 budget saw its biggest year- misuse and weather-related emergencies. The over-year uptick ($1.079 billion, including $480 agency has expanded its substance misuse efforts million in one-time funding for laboratory in the past few years, but more resources are facilities)20 over the past decade.21 A third of these needed to address underlying causes, such as additional dollars—about $350 million—were the impact of trauma or the lack of supportive meant to support the response to the devastating school and community environments.14 Its opioid epidemic.22 Of the CDC’s funds that go funding for effective obesity and community to states, support ranged in FY 2018 from $17.09 prevention programs is inadequate to sufficiently per person in New Jersey to a high of $63.28 per support every state.15 Despite rapid growth in person in Alaska. (See Table 1.) the elderly population,16 funding to support healthy aging at the CDC is minimal. Recent Looking further back, the CDC’s budget fell by 10 increases to funding for public health emergency percent over the past decade (FY 2010-19), after preparedness, including for weather-related adjusting for inflation.23 (See Figure 2.) * he FY 2018 CDC budget was $8.229 billion. However, appropriately comparing this to the FY 2019 budget requires ac- T counting for the FY 2019 transfer of funding for the Strategic National Stockpile ($603.9 million) from the CDC to the Assistant Secretary for Preparedness and Response, and excluding FY 2018 one-time lab funding ($480 million). After APRIL 2019 making these deductions, the adjusted FY 2018 budget was $7.145 billion. The FY 2019 budget of $7.288 billion represents a $143 million increase over FY 2018. 4 Figure 2: CDC Program Funding Fell Over Decade CDC program funding, adjusted for inflation, FY 2010-19 $9 $0.22 $8 $0.82 $0.70 $0.91 $0.94 Funding, FY 2019 dollars (billions) $7 $0.90 $0.95 $0.93 $0.80 $0.51 $6 $5 $4 $7.88 $7.16 $6.83 $6.41 $6.50 $6.41 $6.80 $6.52 $7.59 $6.48 $3 $2 $1 $0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Fiscal Year ■ Prevention and Public Health Fund ■ Other program funding Note: Appropriately comparing funding levels in FY 2018 and FY 2019 requires accounting for the transfer of funding for the Strategic National Stockpile from the CDC to the Assistant Secretary for Preparedness and Response in FY 2019, and excluding one-time lab funding in FY 2018. Data were adjusted for inflation using the Bureau of Economic Analysis’s implicit price deflators for gross domestic product Source: CDC annual operating plans TFAH • tfah.org 5 Table 1: CDC Program Funding Transfers to States, FY 2018 Birth Defects, Chronic Health Agency for Toxic CDC-Wide Childhood Emerging HIV/AIDS, Developmental Disease Reform- Toxic Substances and Activities Obesity and Zoonotic Environmental Viral Hepatitis, State Disabilities, Prevention Substances & Disease Registry and Program Demonstration Infectious Health STI and TB Disability and and Health Environmental (ATSDR) Support Project Diseases Prevention Health Promotion Public Health Alabama $2,949,147 $2,753,495 $13,155,772 $1,018,363 $500,000 $9,882,651 Alaska $404,467 $800,000 $667,171 $15,798,700 $1,092,905 $355,958 $2,294,856 Arizona $900,000 $900,000 $2,344,563 $15,775,146 $1,607,612 $1,330,269 $10,036,550 Arkansas $419,585 $2,034,943 $1,584,350 $11,609,849 $200,990 $4,018,043 California $856,060 $1,157,405 $12,258,366 $215,319 $40,573,997 $10,050,215 $4,167,901 $99,531,702 Colorado $833,451 $2,647,439 $6,892,624 $13,182,251 $5,285,240 $3,267,561 $10,170,700 Connecticut $528,752 $399,954 $2,525,322 $9,282,485 $5,554,587 $1,961,269 $5,851,662 Delaware $145,870 $393,450 $7,984,481 $835,470 $423,550 $2,450,808 D.C. $325,000 $9,418,212 $8,062,187 $19,344,216 $6,682,133 $3,017,346 $26,240,239 Florida $443,878 $759,993 $16,911,400 $19,060,996 $2,353,591 $2,473,601 $56,220,566 Georgia $239,040 $6,402,200 $11,921,868 $49,813,153 $7,287,961 $1,756,156 $35,165,251 Hawaii $266,509 $1,405,406 $5,102,222 $2,551,862 $1,070,000 $3,522,682 Idaho $212,073 $150,000 $703,943 $6,412,585 $673,866 $1,688,404 Illinois $925,000 $2,039,782 $4,289,414 $29,086,341 $6,073,806 $2,307,941 $26,949,380 Indiana $215,682 $2,688,357 $7,817,923 $1,989,112 $1,522,435 $7,266,177 Iowa $2,059,998 $1,929,457 $8,382,072 $3,418,798 $1,499,670 $2,900,479 Kansas $817,967 $1,580,512 $9,437,599 $1,441,595 $1,387,047 $2,376,162 Kentucky $507,191 $2,253,617 $12,548,836 $865,568 $1,247,125 $5,120,172 Louisiana $299,810 $681,538 $16,056,291 $13,092,516 $1,099,723 $1,409,789 $13,282,814 Maine $150,000 $1,514,652 $5,550,049 $779,257 $2,134,958 $1,689,674 Maryland $3,714,637 $20,071,955 $750,000 $22,982,613 $15,808,617 $3,895,681 $21,403,036 Massachusetts $420,000 $2,082,026 $4,725,629 $15,440,524 $8,144,382 $3,490,195 $16,798,772 Michigan $505,853 $1,682,060 $7,187,593 $22,398,464 $4,227,747 $6,321,497 $14,726,728 Minnesota $469,654 $1,267,090 $6,873,596 $18,558,826 $11,964,055 $2,788,527 $6,736,066 Mississippi $150,000 $3,004,802 $12,801,159 $431,905 $1,100,750 $6,526,529 Missouri $380,338 $1,572,536 $4,354,769 $11,034,449 $1,523,594 $2,271,670 $9,519,075 Montana $236,725 $415,000 $1,301,957 $9,496,621 $1,896,917 $475,000 $2,499,999 $1,528,520 Nebraska $166,250 $3,051,304 $10,846,185 $2,503,688 $586,163 $2,278,354 Nevada $398,966 $797,739 $10,652,681 $535,425 $799,637 $5,034,562 New Hampshire $590,000 $2,650,646 $7,628,707 $572,997 $3,303,425 $1,438,845 New Jersey $640,498 $1,010,000 $5,076,047 $8,446,241 $2,795,279 $2,435,387 $24,825,279 New Mexico $2,575,402 $11,270,901 $2,636,397 $2,039,149 $3,043,503 New York $573,050 $5,471,935 $12,221,907 $31,278,443 $16,323,107 $6,533,502 $83,000,696 North Carolina $319,084 $3,441,073 $4,845,970 $18,068,109 $4,060,097 $1,080,365 $19,303,659 North Dakota $150,000 $621,797 $6,240,246 $1,272,926 $1,538,841 Ohio $499,456 $549,992 $7,811,989 $12,790,042 $5,764,691 $1,445,750 $15,078,026 Oklahoma $360,000 $1,763,783 $11,544,856 $1,541,665 $560,358 $4,975,898 Oregon $484,352 $887,629 $1,278,933 $18,390,926 $4,909,284 $2,303,806 $6,524,737 Pennsylvania $480,284 $316,985 $8,028,754 $20,655,684 $2,930,894 $2,122,224 $24,853,140 Rhode Island $310,000 $800,086 $9,606,414 $2,242,960 $2,151,272 $2,524,688 South Carolina $3,449,588 $2,068,312 $15,327,705 $1,750,847 $600,750 $9,772,457 South Dakota $390,559 $9,518,372 $1,158,980 $1,520,075 Tennessee $305,258 $537,718 $2,739,057 $11,023,166 $7,539,384 $1,208,352 $12,483,758 Texas $392,173 $731,660 $29,589,802 $19,555,564 $2,595,527 $2,161,991 $53,017,422 Utah $235,314 $1,612,628 $1,628,933 $13,212,940 $4,836,120 $2,878,698 $2,401,202 Vermont $300,000 $460,261 $5,423,028 $1,664,540 $2,250,466 $1,398,426 Virginia $646,218 $196,691 $19,470,631 $20,179,330 $4,499,649 $2,035,231 $17,764,819 Washington $336,959 $1,675,032 $20,974,741 $6,840,690 $2,260,545 $13,364,591 West Virginia $1,514,664 $9,352,208 $1,096,817 $627,108 $2,291,783 Wisconsin $458,843 $1,637,437 $3,291,841 $13,726,213 $6,050,274 $2,484,236 $4,861,417 Wyoming $148,225 $434,706 $4,375,007 $1,386,410 $1,512,712 United States $13,434,216 $67,990,915 $261,044,901 $965,319 $745,811,554 $192,368,519 $94,044,311 $2,499,999 $718,706,588 6 TFAH • tfah.org Table 1: CDC Program Funding Transfers to States, FY 2018 Immunization Public Health World Trade Total State Injury Occupational Public Health Total State and Scientific Vaccines for Center Health Total State Funding, State Prevention and Safety and Preparedness Funding, Respiratory Services Children Programs Funding Per Capita Control Health and Response Per Capita Diseases (PHSS) (WTC) Ranking Alabama $4,064,728 $4,311,404 $1,699,133 $8,948,119 $523,843 $62,273,912 $112,080,567 $22.93 26 Alaska $1,683,924 $6,798,822 $100,966 $5,012,651 $716,731 $10,937,892 $46,665,043 $63.28 1 Arizona $5,716,056 $8,289,743 $1,226,809 $11,460,662 $787,539 $95,545,190 $155,920,139 $21.74 36 Arkansas $2,832,069 $3,689,004 $6,548,590 $138,000 $40,791,695 $73,867,118 $24.51 22 California $30,898,240 $15,280,703 $8,129,844 $62,814,983 $2,691,048 $469,126,431 $757,752,214 $19.16 43 Colorado $5,723,026 $8,312,770 $6,286,941 $10,034,522 $718,769 $50,172,576 $123,527,870 $21.69 37 Connecticut $5,093,096 $7,333,654 $1,776,464 $7,791,742 $554,972 $32,241,644 $80,895,603 $22.64 29 Delaware $1,242,936 $4,922,875 $5,025,646 $344,026 $10,943,601 $34,712,713 $35.89 6 D.C. $6,853,763 $13,587,452 $255,402 $8,908,807 $6,600,195 $11,190,486 $120,485,438 $171.52 Florida $12,293,321 $7,109,820 $3,681,557 $30,109,408 $1,017,194 $266,451,800 $418,887,125 $19.67 41 Georgia $18,704,018 $21,887,850 $890,953 $16,917,159 $4,169,521 $134,321,492 $309,476,622 $29.42 13 Hawaii $1,997,620 $1,046,106 $5,120,020 $1,252,723 $15,862,463 $39,197,613 $27.59 17 Idaho $1,652,209 $3,650,253 $5,214,492 $294,641 $21,930,025 $42,582,491 $24.27 23 Illinois $11,204,625 $10,982,914 $2,692,529 $26,094,419 $1,232,573 $126,281,728 $250,160,452 $19.63 42 Indiana $4,410,325 $7,493,461 $150,000 $11,467,267 $442,645 $72,202,210 $117,665,594 $17.58 49 Iowa $3,045,563 $4,563,548 $4,506,925 $6,711,641 $828,287 $34,322,593 $74,169,031 $23.50 25 Kansas $3,002,228 $14,661,129 $6,974,852 $1,009,180 $26,607,209 $69,295,480 $23.80 24 Kentucky $3,772,993 $11,332,528 $2,886,892 $8,492,609 $272,359 $60,805,321 $110,105,211 $24.64 21 Louisiana $2,586,399 $8,218,660 $252,000 $9,066,745 $1,397,618 $75,302,818 $142,746,721 $30.63 11 Maine $2,217,540 $6,124,959 $5,125,564 $226,592 $14,101,213 $39,614,458 $29.60 12 Maryland $10,572,444 $13,843,478 $7,581,040 $11,935,472 $11,055,379 $68,782,002 $212,396,354 $35.15 8 Massachusetts $4,867,908 $11,670,392 $7,507,067 $13,985,993 $1,460,875 $54,051,111 $144,644,874 $20.96 39 Michigan $10,392,490 $11,598,353 $3,018,528 $17,546,890 $968,607 $89,970,579 $190,545,389 $19.06 44 Minnesota $7,142,200 $6,270,627 $3,700,062 $11,390,381 $428,948 $47,204,219 $124,794,251 $22.24 33 Mississippi $2,888,545 $2,336,007 $130,000 $6,497,623 $81,831 $42,437,047 $78,386,198 $26.25 18 Missouri $4,942,335 $4,771,328 $834,179 $10,835,144 $80,580 $64,320,042 $116,440,039 $19.01 45 Montana $1,317,239 $3,627,577 $329,306 $5,047,625 $254,035 $10,391,486 $38,818,007 $36.54 4 Nebraska $2,112,215 $4,459,529 $2,066,118 $5,434,869 $80,580 $20,554,320 $54,139,575 $28.06 15 Nevada $2,477,147 $4,919,549 $7,020,595 $80,580 $35,050,565 $67,767,446 $22.33 31 New Hampshire $1,699,032 $5,881,996 $294,904 $5,198,236 $80,580 $10,549,918 $39,889,286 $29.41 14 New Jersey $6,313,733 $6,928,070 $1,037,491 $15,175,449 $280,580 $77,263,717 $152,227,771 $17.09 50 New Mexico $3,760,751 $8,390,097 $627,356 $7,160,392 $102,580 $30,681,497 $72,288,025 $34.50 10 New York $18,649,575 $13,520,378 $5,623,815 $38,184,315 $2,106,642 $241,962,766 $23,293,527 $498,743,658 $25.52 19 North Carolina $7,087,649 $14,650,796 $2,218,404 $14,582,687 $103,831 $121,774,859 $211,536,583 $20.37 40 North Dakota $1,648,604 $2,451,661 $5,130,972 $81,831 $7,467,522 $26,604,400 $35.00 9 Ohio $8,747,744 $11,794,341 $2,135,754 $17,779,802 $80,580 $122,138,493 $206,616,660 $17.68 47 Oklahoma $3,416,636 $7,920,192 $69,269 $7,739,019 $169,831 $58,275,508 $98,337,015 $24.94 20 Oregon $5,356,476 $7,466,135 $1,462,922 $8,246,712 $61,873 $35,446,146 $92,819,931 $22.15 34 Pennsylvania $12,421,654 $12,963,623 $2,168,920 $18,813,229 $120,605,132 $226,360,523 $17.67 48 Rhode Island $1,333,212 $8,000,290 $498,296 $5,044,108 $11,680,470 $44,191,796 $41.80 3 South Carolina $3,676,029 $5,429,439 $9,809,414 $63,393,894 $115,278,435 $22.67 28 South Dakota $1,416,305 $2,781,991 $5,025,646 $10,132,569 $31,944,497 $36.21 5 Tennessee $8,569,928 $10,167,618 $492,968 $11,067,847 $92,503 $84,345,212 $150,572,769 $22.24 32 Texas $22,601,977 $6,376,022 $4,488,005 $38,124,522 $102,157 $448,578,843 $628,315,665 $21.89 35 Utah $2,868,145 $8,532,898 $1,686,041 $6,903,980 $25,559,748 $72,356,647 $22.89 27 Vermont $1,287,517 $5,047,097 $58,143 $5,023,301 $190,984 $6,902,817 $30,006,580 $47.91 2 Virginia $8,731,032 $18,319,443 $101,320 $16,712,227 $3,990,341 $66,565,530 $179,212,462 $21.04 38 Washington $6,472,239 $10,747,059 $5,469,259 $12,364,803 $66,000 $88,430,155 $169,002,073 $22.43 30 West Virginia $1,177,192 $7,768,062 $391,795 $5,227,058 $21,084,481 $50,531,168 $27.98 16 Wisconsin $8,743,427 $9,712,184 $1,906,682 $12,389,562 $88,000 $42,576,269 $107,926,385 $18.56 46 Wyoming $1,147,853 $1,475,665 $4,873,433 $5,359,478 $20,713,489 $35.85 7 United States $312,833,912 $419,419,552 $90,434,059 $618,111,204 $47,308,184 $3,764,948,692 $23,293,527 $7,373,215,452 $22.54 N/A Note: The District of Columbia was excluded from per capita state rankings. The U.S. total reflects grants and cooperative agreements to all 50 states and the District of Columbia, but does not include territories, for the purpose of comparability. Source: CDC Grant Funding Profiles TFAH • tfah.org 7 Prevention and Public Health Fund about $586.5 million of the annual Table 2: The CDC Directs Eleven percent of the CDC’s FY 2019 $800.9 million was transferred to state Most of Its PPHF Funding to budget ($804.5 million) consists of and local partners, including grants States and Localities funding for the Prevention and Public for infectious disease control, the Prevention Fund grants awarded, Health Fund (i.e., the Prevention Preventive Health and Health Services by state, FY 2018 Fund or PPHF),24 the first dedicated Block Grant, immunizations, tobacco State Grants awarded and mandatory funding source for cessation, and other core public health Alabama $8,578,608 programs.27 (See Table 2.) Alaska $4,207,878 prevention and public health within Arizona $13,295,761 the federal budget.25 The Prevention Despite the Prevention Fund’s purpose Arkansas $4,414,571 Fund is intended, by statute, to of improving health and restraining California $48,080,797 “improve health and help restrain the Colorado $10,071,340 health care costs, it has been repeatedly Connecticut $11,259,100 rate of growth in private and public cut and used to pay for other legislation. Delaware $5,107,449 sector health care costs.”26 There is a growing gap between the D.C. $10,459,568 Florida $17,522,646 Most of the CDC’s appropriation of funds that were originally enacted and Georgia $22,159,836 the Prevention Fund—some of the actual/scheduled funding. (See Figure Hawaii $4,633,785 fund is sequestered or appropriated to 3.) For instance, the fund will lose Idaho $5,198,148 $1.35 billion over 10 years under the Illinois $18,198,025 other agencies—is directed to state and Indiana $7,655,796 local prevention efforts. In FY 2018, Bipartisan Budget Act of 2018.28 Iowa $8,531,718 Kansas $7,370,967 Kentucky $9,109,004 Louisiana $10,902,156 Maine $6,313,978 Maryland $14,837,657 Massachusetts $13,716,952 Michigan $17,936,400 Minnesota $14,255,101 Mississippi $5,816,887 Missouri $12,012,267 Montana $6,942,962 Nebraska $8,535,268 Nevada $4,052,390 New Hampshire $4,895,379 New Jersey $14,630,142 New Mexico $9,976,828 New York $34,989,731 North Carolina $12,919,531 North Dakota $4,899,289 Ohio $16,623,716 Oklahoma $8,873,239 Oregon $10,846,938 Pennsylvania $18,113,233 Rhode Island $6,176,555 South Carolina $8,686,192 South Dakota $5,704,024 Tennessee $13,719,125 Texas $26,675,142 Utah $7,323,524 Vermont $3,504,894 Virginia $15,808,128 Washington $11,016,724 West Virginia $4,940,213 Wisconsin $13,061,442 Wyoming $1,936,209 Source: CDC Grant Funding Profiles g0d4ather / Shutterstock.com 8 TFAH • tfah.org Figure 3: String of Cuts to Prevention Fund Since Creation Prevention Fund funding, FY 2010-28 $2,000 $2,000 $1,750 $1,500 $1,500 Funding (millions) $1,250 $1,250 $1,000 $1,000 $750 $750 $500 $500 $949 $928 $927 $932 $931 $840 $844 $950 $950 $1,000 $1,000 $1,300 $1,300 $1,800 $1,800 $250 $0 $51 $72 $73 $68 $69 $60 $56 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028+ ■ Originally enacted ■ Actual/scheduled funding after cuts ■ Sequestration Notes: The original allocations (blue bars) were established by the Patient Protection and Affordable Care Act (ACA) (P 110-48), while cuts (red bars) .L. were established by the Bipartisan Budget Act of 2018 (P 115-123, Current Law). .L. Source: TFAH analysis of congressional committee reports Funding for key CDC initiatives determinants of health,” the local The CDC supports both cross-cutting economy, education level, public aspects of public health, such as public safety, and access to quality education, health infrastructure and workforce, economic opportunity, transportation, as well as issue-specific efforts, such and housing all contribute to wellness as emergency preparedness, chronic and life expectancy.30,31 Social disease and obesity prevention, and determinants account for 80 percent substance misuse and suicide prevention. of health outcomes, yet funding to address them lags.32 Despite overall increases in program funding from FY 2017-19, the CDC’s Governments, nongovernmental budgets for many of these initiatives organizations, and community remain insufficient to support all states members must work together to and localities29 and they have remained improve social determinants and better flat or seen only slight increases over the health of the population, rather the past decade. This section describes than one individual at a time.33 For funding trends for several key programs. example, community partnerships have developed and advocated for Community prevention healthy food retailers in low-income Community conditions have a neighborhoods; engaged in “Complete major impact on health and well- Streets” planning that addresses the being. Often referred to as “social needs of pedestrians, bicyclists, and TFAH • tfah.org 9 transit riders; reduced exclusionary community-chosen and culturally- disciplinary practices to create more adapted strategies to reduce the supportive school environments; and leading causes of chronic conditions, launched multimedia campaigns to increase health literacy, and strengthen reduce tobacco use. community-clinical links. While total funding for these programs increased Such proven community prevention by $5 million in FY 2019, all increases strategies improve a wide range in funding since FY 2017 have been of health outcomes, from chronic directed to the latter program. disease to substance misuse to injury and violence.34,35 These strategies can Public health emergency also produce a substantial return on preparedness and response investment—for example, school- The CDC’s Public Health Emergency based violence prevention efforts can Preparedness (PHEP) cooperative achieve a return ranging from $22 to agreement is the main source of $66 for every $1 spent and tobacco federal support for state and local control mass media campaigns have public health emergency preparedness demonstrated returns ranging from $7 and response.38 From FY 2003-19, the to $74 per $1 spent.36 CDC’s funding for state and local However, current funding for the preparedness was cut by a third. CDC’s community prevention Recently, there have been small programs is inadequate and often increases, including $10 million in FY means the agency is unable to provide 2018 and $5 million in FY 2019. But funding across the country. For these welcome moves were not nearly example, the CDC’s State Physical enough to restore lost resources, nor to Activity and Nutrition (SPAN) Program, prepare for public health emergencies which focuses on improving nutrition that are becoming more frequent and and encouraging physical activity severe. (See Figure 4.) through early care and education, The CDC’s ongoing investments in breastfeeding, food service guidelines, preparedness and response help to street design, and other local efforts, ready health departments for many has only enough funding in FY 2019 to types of emergencies. However, support programs in 16 states.37 extraordinary or novel outbreaks Another example is the Racial and or disasters occasionally require Ethnic Approaches to Community additional—typically one-time— Health (REACH) program, which is supplemental funding, as was the case advancing evidence-based, community- during the threats associated with level strategies and tailoring them to Ebola and Zika. In the past, there eliminate racial and ethnic health have been delays in passing such disparities in chronic disease and supplemental funding, postponing related risk factors. Since FY 2017, emergency response efforts. There REACH grantees experienced a $53 are two preliminary efforts to help million diversion in funds to the Good prevent such delays: Health and Wellness in Indian Country l T he FY 2019 Labor-HHS-Education program, which supports effective appropriations bill established a 10 TFAH • tfah.org Figure 4: Public Health Emergency Preparedness Funding Has Lost Ground CDC funding for state and local preparedness and response, FY 2003-19 $1,200,000 $1,000,000 Funding (millions) $800,000 $600,000 $400,000 $200,000 $0 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16 FY17 FY18 FY19 Note: Data for FY 2003 to 2015 reflect “State and Local Preparedness and Response Capabil- ity,” with additions in FY 2003 (smallpox supplement) and FY 2004 (Cities Readiness Initiative and U.S. Postal Service Costs). Data for FY 2016 to 2019 reflects the sum of funding for “Public Health Emergency Preparedness Cooperative Agreement” and “Academic Centers for Public Health Preparedness.” This difference was owed to a change in the CDC’s reporting practice in its annual operating plans. Source: CDC annual operating plans new $50 million Infectious Diseases l T he Secretary of the Department of Rapid Response Reserve Fund Health and Human Services (HHS) (IDRRRF) that could be tapped to is authorized under the Public prevent, prepare for, or respond to Health Service Act to access money an infectious disease emergency.39 from the Public Health Emergency Although housed at the CDC, Fund (PHEF) during a declared funds could be transferred to public health emergency. However, other Public Health Service Act as of the writing of this report, the programs, as necessary. PHEF had no balance, according to federal officials.40 The Pandemic With such a mechanism, money and All-Hazards Preparedness would be targeted for responses and Advancing Innovation Act, to outbreaks, which are often which passed the U.S. House of underfunded. It would also help Representatives in 2018 and in ensure a timely response by January 2019, strengthens the health departments. However, PHEF (renaming it to Public Health many public health emergencies Emergency Rapid Response Fund), are not infectious in nature and including by clarifying triggers and the demands of addressing most potential uses.41 However, Congress major outbreaks far exceed $50 would still need to appropriate million, especially if medical money into the Fund. countermeasures are required. TFAH • tfah.org 11 Chronic disease prevention A majority of U.S. adults, especially Figure 5: CDC Current Chronic Disease Funding Lags FY 2012 Level elderly adults, have a chronic disease, Chronic disease funding, adjusted for inflation, FY 2010-19 and 40 percent have two or more.42 As a $1,500 Funding, FY 2019 dollars (millions) result, chronic diseases are the leading cause of death and disability in the $1,200 country, and 90 percent of annual health $69 $346 $463 $483 $359 $253 $255 $257 $482 $352 care expenditures are for people with $900 chronic and mental health conditions.43 $600 Because most chronic diseases are $1,056 $889 $852 $850 $802 $797 $886 $808 $932 $933 preventable,44 sufficient investments $300 in related public health programing is $0 key to improving health outcomes and FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2018 FY 2019 reducing health care costs. The CDC ■ Chronic disease prevention and health promotion — PPHF ■ Other chronic disease and health promotion spends nearly $1.2 billion annually to prevent chronic diseases. Adjusted for Note: Data were adjusted for inflation using the Bureau of Economic Analysis’s implicit price deflators for gross domestic product. inflation, the CDC’s chronic disease Source: CDC annual operating plans funding in FY 2019 was below its FY 2012 level.45 (See Figure 5.) Substance misuse and suicide prevention prescribing. But, given the continued In addition to substance misuse, the escalation in substance use disorder CDC’s National Center for Injury In response to the need for public deaths, these funds are still inadequate Prevention and Control has identified health approaches to prevent substance to address the crisis. suicide and adverse childhood misuse and overdose, the CDC has experiences as key priorities, given rapidly expanded its substance misuse To facilitate multi-faceted prevention the intersection and shared risk and efforts in recent years. Its annual efforts, the CDC is in the process of protective factors across these health funding for opioid overdose prevention merging separate programs into a issues. Nevertheless, few federally funded and surveillance in FY 2018 and FY 2019 single grant program called Overdose programs exist that target underlying rose to $475 million, an increase of $350 Data to Action—or OD2A—grants.47 causes of substance misuse and suicide, million from FY 2017.46 The agency’s Grants will begin to be awarded in fall such as the impact of trauma or lack activities have included grants to states 2019. In addition to supporting core of conditions and environments that and large local health agencies to activities described above, this grant will build resiliency and coping skills (e.g., implement and strengthen prescription also allow states to support innovative supportive school environments and drug monitoring programs; expand community-based prevention efforts, availability of mental health services), the surveillance of substance-related though it is unclear how much funding and the programs that do exist are overdoses; and promote appropriate will go to that purpose. limited in their geographic coverage. 12 TFAH • tfah.org Federal Funding for Combatting the Opioid Epidemic The Substance Abuse and Mental program. The DFC grant provides Health Services Administration community coalitions with resources (SAMHSA), the Office of National Drug to create and sustain programs for Control Policy (ONDCP), and other reducing youth substance abuse by federal agencies do much to develop building infrastructure among local and advance policies and programs to partners. This program has supported reduce opioid overdoses and deaths. community coalitions that have been linked to declines in the use of alcohol, SAMHSA has recently expanded existing tobacco, and marijuana. Nevertheless, programs and established new grant the program received only a $5 million programs and technical assistance increase in funding from FY 2016-19. initiatives. In FY 2019, SAMHSA was appropriated $1.5 billion for State The SUPPORT for Patients and Opioid Response Grants, which can be Communities Act, enacted in used to provide prevention, treatment, October 2018, includes Medicaid- and recovery services.48 and Medicare-related provisions that increase access to evidence- In contrast, the Substance Abuse based treatment and follow-up care, Prevention and Treatment (SAPT) particularly for pregnant women, Block Grant, which focuses broadly on children, residents of rural areas, older substance misuse, has not received Americans, and people in recovery a significant increase in more than from substance use disorder.52 The a decade.49 This grant distributed law also authorizes a small grant to states and territories constitutes program for state agencies to carry a substantial amount of states’ out evidence-based or promising substance misuse budgets and funds practices for prevention, recovery, services for 1.5 million Americans.50 and treatment support for children, The grant requires at least 20 percent adolescents, and young adults. While of its funds to be used toward primary investments in treatment and recovery prevention. It makes up 100 percent are critical—and still underfunded— of substance use prevention efforts in they alone cannot alter the trajectory six states and a majority of prevention of the opioid epidemic. Increased funding for 35 states.51 funding needs to be allocated to The ONDCP administers the Drug- prevent substance misuse and Free Communities (DFC) grant addiction in the first place.53 TFAH • tfah.org 13 Healthy aging The number of Americans age 65 or nutrition, family caregiver support, older is projected to more than double transportation, protection from abuse, over the next 40 years, rising from 15 and other local services. Historically, percent to nearly 24 percent of the U.S. there has been little collaboration population.54 But resources to promote between public health and AAAs. Age- the health of this population are friendly public health systems could inadequate. There is not a Healthy Aging align with and complement such aging unit at the CDC, where support is limited sector programs and services to help to its Healthy Brain Initiative and a small foster the conditions in which older program to help seniors prevent falls. adults can live healthy, independent, and productive lives. Federal programs that address older adult health continue to be siloed and At the state level, recent pilot efforts under-resourced, undermining progress in Florida to create age-friendly public toward a systems approach to improve health activities have demonstrated the health and well-being of older adults. the value of prioritizing such work. The Office of the Assistant Secretary for With limited private funding, the state Health at the U.S. Department of Health and local public health departments and Human Services is promoting have developed county-specific data the value of expanding age-friendly reports, reviewed and strengthened public health in partnership with the core programs, such as emergency Administration for Community Living preparedness plans, and joined with (ACL). The ACL administers programs partners in other sectors to improve that serve older adults through the the social determinants of health for Older Americans Act, funding local Area older adults. Agencies on Aging (AAAs) to support 14 TFAH • tfah.org The broader federal funding landscape In addition to the CDC, other offices of nutritionally at-risk infants and l H ousing quality directly affects and agencies within the Department children, and decrease iron deficiency health, while affordability and of Health and Human Services are anemia in children.61 stability, and the stresses they bring, engaged in public health work and have more indirect effects.68 The The 2018 Farm Bill held steady require adequate resources to improve Department of Housing and Urban benefits and requirements for the the health and well-being of America’s Development (HUD) received a Supplemental Nutrition Assistance residents. Such agencies include $3.9 billion increase in FY 2018, Program (SNAP), which assists about the Food and Drug Administration strengthening a number of affordable 40 million low-income Americans. A (FDA) (e.g., protects the safety housing and community development February 2019 proposed rule would of foods, drugs, medical devices, programs.69 Despite deep cuts to establish stricter work requirements for cosmetics, and tobacco products), HUD in the President’s proposed SNAP beneficiaries who are able-bodied the Health Resources and Services FY 2019 budget, Congress increased adults without dependents.62 According Administration (HRSA) (bolsters funding for HUD by $1.5 billion (3.5 to the Department of Agriculture’s own health care services for people who are percent), including slight increases estimates, this proposed rule would cause geographically isolated or economically for affordable housing programs.70 more than 755,000 people to lose SNAP or medically vulnerable), and the benefits. Access to SNAP at early ages l W alkable, bikeable, transit-oriented Substance Abuse and Mental Health can lower rates of diabetes, heart disease, communities have been shown to Services Administration (SAMHSA) and obesity, among other conditions, improve health by enabling more (leads federal public health efforts and improve non-health outcomes, such physical activity and reducing air surrounding behavioral health). These as high school graduation, employment pollution and traffic injuries.71 The agencies saw some changes to their status, and earnings.63,64 2018 Department of Transportation budgets in FY 2019, with increases for budget included funding for FDA ($5.37 billion to $5.5 billion),55 Funding for a range of activities the Transportation Alternatives SAMHSA ($5.65 to $5.74 billion),56 and in other sectors, including Program and new transit projects, HRSA ($6.73 billion to $6.85 billion).57 education, environment, housing, and it tripled funding for TIGER transportation, and agriculture, also Safety-net programs within the (Transportation Investment have important implications for Department of Agriculture help Generating Economic Recovery) health outcomes and costs. Americans maintain or improve their grants, which support trail projects health. For example, access to sufficient l E ducation contributes to health and and Complete Streets projects that nutrition and healthful food choices quality of life,65 and school policies, provide safe access for all users.72 has a positive impact on people’s health programs, resources, and climate The Department of Transportation’s and reduces health care spending.58 affect physical and mental health FY 2019 budget reflects a 3 percent outcomes.66 Congress increased the decrease from FY 2018 (from $27.3 Despite food insecurity affecting Department of Education’s funding billion to $26.5 billion).73 one in eight Americans, federal by $581 million in FY 2019, including nutrition assistance resources remain Given the importance of the social increases to Title I, which funds underfunded. For instance, FY 2019 determinants of health, the value services for disadvantaged students; funding for the Special Supplemental of much of the work of these varied Special Education; Student Support; Nutrition Program for Women, Infants, agencies is noteworthy. Their efforts Academic Achievement State Grants, and Children (WIC), which helped to build a broad, unified cross-sector which contribute to school safety and nearly seven million low-income and vision of the home and community supportive school environments; and nutritionally at-risk pregnant women, conditions necessary for optimal Education for Homeless Children new mothers, and children under health, if sufficiently funded, will pay and Youth. Funding for Head Start, age five in FY 2018,59 was cut by $175 health and economic dividends in the which is part of the Department of million.60 WIC participation can coming years. Health and Human Services’ budget, reduce infant mortality and rates of was increased by $200 million.67 low birthweight, improve the growth TFAH • tfah.org 15 2 State Public Health Funding SECTION 2: State Public Health Funding State health agencies play a key role in promoting public health and supporting local health departments. They directly engage in population- based primary prevention, developing preparedness plans and coordinating emergency responses, combatting the opioid epidemic, and conducting lab testing, disease surveillance, and data collection.74 Many are expanding and modernizing their work to include a stronger focus on “upstream” or primary prevention policies and programs (for more information, see TFAH’s “Promoting Health and Cost Control in States” report), a commitment to the promotion of equity as a core value in all of their work, and an expansion of their partnership with health care and with non-health sectors. The ability of state health departments to fulfill public health funding in Alaska, Maine, and Texas these roles is heavily affected by federal funding, were down more than 10 percent. A majority of which is a primary source of state public health states maintained or increased their public health money. Total state spending on public health funding for the year. Nevada’s rose by 30 percent, increased by 2 percent in FY 2018. and Hawaii, Kansas, Louisiana, Michigan, North Dakota, and Washington each increased their Seventeen states and the District of Columbia funding by more than 10 percent. cut their public health funding in FY 2018. (See Table 3.) While most cuts were relatively small, APRIL 2019 16 Matthew Corley / Shutterstock.com Table 3: State Public Health Funding Held Stable or Increased in 33 states Public health funding, by state, fiscal 2017–2018 FY 2018 funding Percentage change Alabama $279,005,845 1.7% Alaska $71,402,600 -13.8% Arizona $68,068,700 -0.1% Arkansas $151,852,956 -2.8% California $2,588,903,000 2.8% Colorado $282,495,722 1.5% Connecticut $110,991,051 6.5% Delaware $39,032,300 -1.8% D.C. $93,891,000 -1.1% Florida $390,814,976 0.8% Georgia $233,484,497 6.4% Hawaii $170,347,276 10.5% Idaho $153,165,500 1.3% Illinois $331,737,880 1.6% Indiana $92,570,257 9.7% Iowa $126,229,296 -0.5% Kansas $41,094,981 16.8% Kentucky $152,460,883 -6.3% Louisiana $112,010,181 16.4% Maine $23,621,513 -17.1% Maryland $255,460,086 5.0% Massachusetts $523,761,131 1.1% Michigan $151,414,400 18.0% Minnesota $244,955,000 -0.1% Mississippi $42,993,213 -9.9% Missouri $43,164,251 3.7% Montana $23,754,145 -5.9% Nebraska $89,234,681 4.1% Nevada $25,223,708 30.2% New Hampshire $30,836,781 2.9% New Jersey $251,431,000 5.2% New Mexico $283,269,500 -1.8% New York $1,645,336,100 -4.5% North Carolina $157,214,360 6.0% North Dakota $40,858,480 12.2% Ohio $153,239,809 5.8% Oklahoma $153,322,000 -5.4% Oregon $116,277,440 2.7% Pennsylvania $185,520,000 7.5% Rhode Island $55,949,621 0.4% South Carolina $131,206,566 9.4% South Dakota $30,613,700 -3.5% Tennessee $332,445,000 -1.2% Texas $479,210,971 -12.1% Utah $103,768,200 3.9% Vermont $29,609,249 -1.3% Virginia $322,331,204 0.5% Washington $341,908,500 13.5% West Virginia $108,316,602 3.4% Wisconsin $100,942,600 1.0% Wyoming $30,894,959 0% 51-state total $11,877,166,374 2.0% Note: Owing to differences in organizational responsibilities and budgeting, funding data are not necessarily comparable state to state. See TFAH’s “Ready or Not: 2019” report, Appendix: Methodology for a description of TFAH’s data-collection process, including its definition of public health funding. Source: TFAH analysis of states’ public health funding data. TFAH • tfah.org 17 3 Local Public Health Funding SECTION 3: Local Public Health Funding Local public health departments engage their residents and coordinate partners to address public health issues in their community. These agencies help protect the food and water supply, provide immunizations, conduct surveillance to detect and monitor infectious diseases, prepare for and respond to disasters and emergencies, combat the opioid epidemic, and offer other public health services and education.75 Like their state counterparts, they are adjusting the shape of their work. For example, many have reduced their provision of direct services as more Americans gained health insurance, and increased their attention to policies that promote well-being (e.g., Cityhealth, an initiative of the de Beaumont Foundation and Kaiser Permanente). Spending cuts at the federal and state level have Eighteen percent of medium-sized local health serious consequences for local health departments departments—those serving populations between and the communities they serve, given that such 50,000 and 499,999—reported budget cuts in FY allocations constitute a substantial portion of local 2017. Approximately a quarter of all small local health departments’ budgets. health departments—those serving populations below 50,000—experienced budget cuts in both One-fifth of local health departments (21 FY 2017 (23 percent) and FY 2016 (24 percent).77 percent) reported decreases in their FY 2017 budgets, according to a spring 2018 survey. A Public health funding cuts at the federal, state, slightly higher percentage (23 percent) also and local levels undermine efforts to hire, train, experienced cuts in the previous year.76 and retain a strong public health workforce, which in turn limits governments’ ability to The percentage of large local health effectively protect and promote the health of departments—those serving populations of their communities. Multiple years of funding cuts 500,000 or more—reporting budget cuts in FY contributed to more than 55,000 lost jobs at local 2017 almost doubled over the previous year (19 health departments from 2008-17.78 percent, compared to 10 percent in FY 2016). APRIL 2019 18 4 Public Health Infrastructure SECTION 4: Public Health Infrastructure To provide all Americans with an adequate level of public health protection, every health department must possess foundational capabilities, including those pertaining to assessment, all-hazards preparedness, policy development/ support, communications, community partnerships, organizational competencies, and accountability/performance management.79,80 The CDC plays a key role in supporting public negative health outcomes and health disparities. health capacity across more than 3,000 state, According to recent analyses, there is a $4.5 local, territorial, and tribal public health billion gap between current funding and agencies. But uneven funding creates enormous what is needed to build a strong public health variation81 in such capabilities across the nation’s infrastructure nationwide.82 public health departments, contributing to a katz / Shutterstock.com APRIL 2019 19 5 Recommendations for a Healthier SECTION 5: Recommendations for a Healthier America America Trust for America’s Health recommends the following policy actions and investments to achieve optimal health for all people, in all communities. Increase federal investments in public health Adequately protecting and improving the health percent, compared to its FY 2018 level, by FY of Americans requires greater federal investment 2022, as advocated by the Association of State in public health. Given bipartisan support among and Territorial Health Officials’ “22 by 22” American voters for public health protections,83 campaign. While the $143 million increase that and the proven cost-effectiveness of public health the CDC received in the FY 2019 budget is a interventions and policies,84 investing in public positive development, its discretionary funding health is the most efficient, commonsense way to must increase by an additional $1.5 billion by FY improve health and health equity. 2022 to allow it to properly address the nation’s public health priorities.86 To protect and improve the health and well-being of all Americans, TFAH recommends that Congress For FY 2020, TFAH recommends increases to and the President take the following actions. adequately support the agency’s evidence-based public health efforts, including in the following areas. Raise overall budget caps When the Bipartisan Budget Act of 2018 expires The Prevention and Public Health Fund at the end of FY 2019, public health and other The Prevention and Public Health Fund has made federally funded domestic discretionary programs critical investments in evidence-based programs, face a scheduled cut of $55 billion—11 percent if including expanding vaccine infrastructure, applied across-the-board, adjusted for inflation.85 building laboratory and surveillance capacity, and Cuts of this magnitude would be devastating promoting tobacco cessation. to public health prevention and preparedness Against its authorized purpose, the PPHF has programs. To avoid this funding cliff, lawmakers been used to support programs outside the will need to enact a new bipartisan budget deal realm of prevention and public health, including that raises the overall spending caps and that Medicare physician payments in 2012, the 21st provides appropriators with the funding needed Century Cures Act in 2016, and the Children’s to invest in effective public health programs. Health Insurance Program in 2018.87 While Substantially increase funding for the CDC these programs are important, this shortsighted The CDC is America’s first defense against approach increases costs and worsens health health threats and epidemics and the workforce outcomes in the long run by hampering we count on to improve health and health prevention efforts. Treatment should not be equity. Yet, funding for the agency has not funded at the expense of prevention. kept pace with rising public health needs and As the largest investment in prevention, the changing demographics. Prevention Fund should be protected, cuts in As a first step, Congress and the President future years should be restored, and its funds APRIL 2019 should increase the CDC’s funding by 22 should be used for their authorized purpose. 20 an escalating number of emergencies. Emergency responses are increasing, despite steady funding erosion. There were 18 declared public health emergencies in 2017, compared to 29 combined declared emergencies for the prior 10 years. This funding would help restore capacity at health departments impacted by cuts, especially those that responded to an unprecedented number of emergencies in recent years. Increased funding is also needed for preparedness programs under the Assistant Secretary for Preparedness and Response, including the Hospital Preparedness Program (HPP), which provides funding and technical assistance to every state and territory to Community prevention prepare the health system to respond Community-level work to prevent SPAN replaced State Public Health and recover from disasters; as well illness and address social determinants Action grants in 2018. While SPAN as programs that support research, of health, such as by changing street now provides funding to implement development, and stockpiling of design to improve pedestrian and evidence-based strategies at state and medical countermeasures. HPP has biker safety or improving housing local levels to improve nutrition and been cut nearly in half over the past quality to reduce the risk of lead physical activity, the current funding 16 years, and funding should increase poisoning, asthma and other health level only supports 16 states; to at least $474 million. (For more conditions, requires significant information, see TFAH’s “Ready or l a n additional $21 million to the Racial resources over the long term. Under Not: 2019” report.) and Ethnic Approaches to Community current funding, the CDC cannot Health (REACH) program to restore Finance a standing response fund provide adequate resources to all prior levels of funding to REACH for emergencies eligible states or communities, leaving grantees, while also maintaining the To ensure a timely public health many underfunded or unfunded for budget for the Good Health and response to major crises, TFAH certain prevention activities, which Wellness in Indian Country program. recommends significant no-year harms health and exacerbates health disparities. Public health emergency funding for one or both of the recently preparedness proposed response funds—the TFAH recommends increasing funding Infectious Diseases Rapid Response for the CDC’s community prevention Congress and the President should Reserve Fund (IDRRRF), established programs and activities, including: increase funding to $824 million in by the FY 2019 Labor-HHS-Education FY 2020—to the levels authorized in l a n additional $40.8 million† in FY appropriations bill and the Public 2006—for the CDC’s Public Health 2020 for the State Physical Activity Health Emergency Fund (PHEF). Emergency Preparedness (PHEP) and Nutrition (SPAN) program to Such funds should be temporary cooperative agreement program to provide all states with resources bridges until supplemental emergency ensure states and localities have the to combat the obesity epidemic. resources are approved. Their resources core resources needed to respond to † This total would extend the program to the remaining 34 states, assuming that states received $1.2 million, on average. TFAH • tfah.org 21 should not be drawn from existing l i ncreasing funding for the ONDCP’s emergency preparedness activities. Drug Free Communities Program to expand community coalitions Substance misuse and suicide that work to prevent and reduce prevention substance misuse; Congress and the President should build on recent investments to reduce l i ncreasing funding for early substance misuse, especially opioid intervention and suicide prevention misuse, by increasing funding for relevant efforts at SAMHSA, such as programs (including suicide prevention) the Garrett Lee Smith Suicide within the CDC’s National Center for Prevention Grant Program; and Injury Prevention and Control and l e stablishing a dedicated funding Division of Adolescent and School Health line for the CDC focused on suicide (DASH), with an emphasis on upstream prevention efforts with public health or primary prevention activities. departments at the federal, state, and TFAH recommends: local levels. l i ncreasing Opioid Abuse and Overdose Numerous interventions and policies Prevention activities at the CDC Injury proven to reduce or prevent substance Center by $175 million, for a total misuse and suicide are also highlighted of $650 million. This funding would in TFAH’s “Pain in the Nation” report. build upon previous efforts to support Surveillance and data federal, state, and local activities like The nation’s public health surveillance provider education and prescription infrastructure relies on antiquated, drug monitoring programs by unconnected systems and methods. adding primary prevention capacity Local, state, and federal data systems at the federal, state, and local levels have not kept pace with current to identify and reduce primary risk technologies and result in delayed factors and promote protective factors detection and response to public health to prevent substance misuse; threats. Cross-cutting investments l i ncreasing funding for the CDC’s are needed to revitalize the CDC’s Division of Adolescent and School data infrastructure, shore up state Health (DASH) and Healthy Schools and local public health surveillance, Program under the Division of and to track environmental threats to Population Health. Both programs health. Public health and health care offer in-school, evidence-based organizations are leading a campaign approaches to equip children and to advocate for $1 billion over 10 adolescents with protective knowledge years to modernize the public health and skills that enable them to avoid surveillance enterprise and build substance misuse and become healthy secure, interoperable systems and a adults. In addition to the students, highly trained workforce.88 such efforts will engage parents, Greater resources are also needed for teachers, and the community; the Behavioral Risk Factors Surveillance l i ncreasing funding for SAMHSA’s Survey, which provides invaluable data Substance Abuse Prevention and to public health agencies. Treatment Block Grant to expand prevention efforts in states; 22 TFAH • tfah.org Healthy aging l a ddressing emergency preparedness The CDC should create a new Healthy planning needs for vulnerable older Aging unit within the Division of adult populations; and/or Population Health to build state and l p romoting policies to improve the local public health department capacity quality of life and health, including to promote the health and well-being by connecting with existing efforts, of older adults. The unit would take such as Age-Friendly Communities. one or more of the following actions: The CDC should coordinate efforts l a ssessing the needs of older adults with the Administration for Community with a focus on those that can Living, other federal agencies, and key be met through public health nonprofit organizations to improve the interventions and result in improved health of older adults. The CDC would overall health and well-being of also identify resources available to older adults, improved health equity, state and local health departments and and reduced healthcare costs; create a repository of resources and l a ssessing and adapting existing evidence-based programs and policies programs and policies with that address the health and well-being significant gaps in meeting the of older adults. health needs of older adults; Every state, the District of Columbia, l d eveloping partnerships with aging and the three largest cities should sector stakeholders to ensure non- receive funding to ensure that the duplication of efforts and increase capacity exists within their public health efficiency by working collaboratively agency to assess and address the public across sectors; health needs of adults age 65 or older. The assessment should focus on needs l i mplementing evidence-based disease that, if met, would optimize health, prevention and health promotion reduce disparities, and reduce health programs and policies that improve care costs. The funding could support a the health of older adults; TFAH • tfah.org 23 dedicated staff person who is an expert such as those supported by the in healthy aging to oversee the work Centers for Medicare & Medicaid and to coordinate with aging sector Services’ Accountable Health stakeholders to implement policies and Communities grantees, to address programs. The CDC should administer identified social needs of patients; and evaluate the effort. l C onvening local and state Social determinants of health organizations, agencies, and Congress should authorize a CDC policymakers from multiple sectors to program to fund local and state agencies review and consider community-wide to gather data, identify priorities, interventions strategies to advance establish plans, and take action to health-promoting social conditions; address unmet non-medical social l P roviding national training and needs, such as those related to housing, technical assistance to grantees food, utilities, safety, and transportation. and other interested parties in the The goal of the program would be to optimal approaches to improving improve health outcomes and reduce health and reducing health health care costs. The program would care costs by addressing social support the following actions: determinants. Eligible organizations l D eveloping local and state could include local and state health partnerships between public health departments and others deemed agencies and health care systems, appropriate by the CDC. Provide sufficient full-year funding for federal agencies Many federal agencies have a hand in As the agreement to increase spending protecting and improving public health. caps under the 2011 Budget Control When government is operating under Act expires, Congress should also raise a short-term continuing resolution—or discretionary spending caps to allow worse, a shut-down—public health and for sufficient investment in public other programs that promote health health and other domestic priorities can be crippled. Congress should pass that impact health, including housing, full-year appropriations measures that education, transportation, and other fund federal agencies for the entire issues. A congressional budget fiscal year. This is essential for effective agreement should also balance new and efficient use of taxpayer dollars and investments between defense and non- planning and maintaining workforce, defense discretionary programs. supplies, and other capacities necessary to support public health activities. 24 TFAH • tfah.org Increase state and local investment in public health, prioritizing social determinants State and local public health become Chief Health Strategists in universal pre-kindergarten and school departments play important roles in their communities, leading efforts to nutrition programs, Complete Streets protecting and promoting the health convene partners across sectors to build policies, housing rehabilitation loan of their residents. TFAH recommends integrated systems that improve health and grant programs, Housing First/ that states and localities increase their and health equity.89 rapid re-housing programs, earned public health funding. State and local income tax credits, earned sick leave, States and localities should also health departments need funding for and paid family leave. (For more invest in evidence-based policies and core programs, and for addressing information on these programs and programs that make communities emerging challenges, such as opioid policies, and the health and economic healthier by improving the conditions and suicide deaths. More broadly, evidence of their effectiveness, see where people live, work, learn, and these public health departments TFAH’s “Promoting Health and Cost play. These include high quality need greater resources in order to Control in States” report.) Work across sectors to improve the effectiveness and efficiency of public health investments Building partnerships across a range of can contribute to the promotion of type of coverage should include: sectors and stakeholders (e.g., health prevention in the delivery of care l a ssistance in securing housing and departments, schools, health care and in their roles as community supportive wrap-around services;92 providers, transportation departments, institutions. There are, in fact, local businesses, faith-based and other mounting cost pressures to develop l p rovision of medically tailored agencies) is one of the strongest innovative approaches that shift from meals (home-delivered if necessary), approaches to improving community the traditional fee-for-service clinical nutrition counseling, and care health.90 Scaling and sustaining such models to value-based ones that management for chronically ill partnerships requires action from those consider and attempt to address the members, or referrals to prescription at all levels—and in varied sectors—of impact of nonclinical factors.91 food clinics with healthy options at no government, as well as the private sector. cost to food-insecure patients;93 These approaches should be expanded. In particular, health care payors and Insurers should incentivize and health l s upport to parents through proven, providers, government agencies, and systems should conduct screening intensive services—sometimes homes the philanthropic community have of their patients for the social delivered—such as the Nurse Family important roles to play in incentivizing determinants of health. Payors should Partnership; and and facilitating cross-sectoral investments. expand their coverage of non-medical l t he 18 proven prevention Health care payors and large health social needs that impact the health and interventions that are part of the systems well-being of patients, such as those CDC’s 6|18 initiative.94 Health care payors—both public and associated with food insecurity and private—and health care systems housing instability. Examples of the TFAH • tfah.org 25 Payors can make it easier for health screen and address beneficiaries’ larger communities in which their care systems to invest in social health-related social needs (e.g., patients live. In doing so, they should determinants by expanding their Accountable Health Communities) prioritize the improvement of the list of allowable interventions. are steps in the right direction. And conditions in neighborhoods with Some private payors, such as Kaiser the Center for Medicare & Medicaid residents who have elevated levels Permanente and Humana, have Innovation Center deserves credit for of preventable illnesses, injuries, already begun to do so. And in the its Accountable Health Communities and deaths. Hospital community public sector, more and more states model, which makes routine the benefit and other hospital funds are exploring how to address these screening for social determinants should be directed to community needs through Medicaid waivers. and the efforts to address them. Such investments in affordable housing and Some state Medicaid programs practices should be widely expanded. economic growth in such geographic are beginning to encourage Given the influential example that areas.97 Health systems can become their contracted managed care the Centers for Medicare & Medicaid “anchor institutions” for those organizations to address social needs, Services set for private insurers,96 neighborhoods, striving to improve such as living environments and these innovations have the potential the social determinants of health—for access to healthful food.95 Section to be adopted by other payors, as well. example, by purchasing, hiring, and 1115 demonstration waivers that investing locally and by supporting In addition to expanding patient give providers financial incentives to total-population policies such as services, payors and health systems provide more efficient and effective those identified by TFAH’s Promoting should also expand their support care (e.g., Delivery System Reform Health and Cost Control in States for improving conditions of the Incentive Payment programs) and project and Cityhealth.98 Medicaid’s Unique Role There is an especially strong business case for Medicaid to through various existing authorities, including by providing invest in addressing the social determinants of health, given housing-related services through home- and community-based the growing body of evidence that interventions targeted at waiver programs; providing food vouchers or pest control those who can most benefit would provide significant health through managed care value-added services; and coordinating care savings. For example, interventions addressing the referrals to community services as part of patient-centered housing and other social needs of this population could make medical homes or Medicaid Health Homes. significant inroads in reducing Medicaid costs.99 Many states are also addressing prevention and social In addition, Medicaid, along with Medicare, the major public determinants through waiver authorities. Several state Medicaid insurance programs, set an example for private insurers.100 agencies have worked with the CDC to implement 6|18 Initiative Thus, innovations in Medicaid have the potential to be preventive interventions to improve health outcomes and lower adopted by other payors, as well. costs, and some states are beginning to use their Accountable Care Organizations to address social determinants such as Medicaid agencies, managed care plans, and provider living environments and access to healthful food.101 organizations can address prevention and social determinants 26 TFAH • tfah.org Government agencies and Ease coordination of funding philanthropists from multiple streams Grantmakers should encourage Making effective cross-sector investments cross-sector collaboration by often requires more flexibility than structuring grants to incentivize federal, state, and local governments and cover the planning and have traditionally provided. Governments infrastructure costs of initiating and should make it easier for grantees to maintaining such work and promote coordinate or combine funding from the braiding of funding streams to diverse sources. Two key mechanisms support multi-sector strategies. for doing so are braiding funding (coordinating funding from multiple Government agencies and sources to support a single initiative philanthropic organizations should or portfolio of interventions at the also support creative approaches to community level) and blending funding facilitate cross-sector investments, (combining separate funding streams such as Prevention and Wellness into one pool, under a single set of Trusts and Pay for Success or Social reporting and other requirements, to Impact Bond models. A Prevention meet needs that are unexpected or and Wellness Trust pools public unmet by other sources). and/or private sources of funding to support prevention and wellness TFAH has compiled a compendium interventions that improve population of resources and examples to help health outcomes.102 For example, the communities as they explore braiding Prevention and Wellness Trust Fund or blending funds to support health of Massachusetts was funded by a one- improvement. TFAH has also issued time assessment of acute hospitals recommendations for how the federal and payors.103 This kind of Trust can government can promote the braiding of supplement limited public resources programs and funding streams,105 many for prevention and enable multi- of which can also be applied to state sector efforts. In the Pay for Success and local governments. It is important or Social Impact Bond model, private that agencies using these options put investors provide upfront capital for safeguards in place to ensure that funds the delivery of services, which are are not reduced or cut (for example, by repaid by a payor—often a government creating block grants that appear to offer payor—only if and when the services greater flexibility but that actually reduce delivered achieve an agreed-upon the ability to address a range of health result.104 This structure can help needs by reducing funding), and that overcome the wrong-pocket problem, those served are not adversely affected when one organization or sector is best by a reduction in benefits or services. positioned to make an investment but With such safeguards in place, agencies another benefits. that take these steps can maximize the effectiveness of existing funding streams, putting government dollars to better use and improving the lives of residents in communities across the nation. 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