The Impact of Chronic Underfunding on America’s Public Health System: Trends, Risks, and Recommendations, 2022

This annual report tracks federal, state, and local investment in public health and how underinvestment in public health programs hobbled the COVID-19 response, exacerbates health inequities, and continues to put Americans' lives and livelihoods at risk.


Rhea Farberman 202-494-0860 [email protected]
Katiana Krawchenko 561-441-3632 [email protected]

(Washington, DC – July 28, 2022) – Chronic underfunding has created a public health system that cannot address the nation’s health security needs, its persistent health inequities, as well as emerging threats, and, was a contributing factor in the inadequate response to the COVID-19 pandemic, according to this TFAH report, The Impact of Chronic Underfunding on America’s Public Health System: Trends, Risks, and Recommendations, 2022.

Lack of funding in core public health programs slowed the response to the COVID-19 pandemic and exacerbated its impact, particularly in low-income communities, communities of color, and for older Americans – populations that experience higher rates of chronic disease and have fewer resources to recover from an emergency. TFAH is one of numerous organizations within the public health community calling for an annual $4.5 billion investment in the nation’s public health infrastructure.

This annual report examines federal, state, and local public health funding trends and recommends investments and policy actions to build a stronger public health system, prioritize prevention, and address the ways in which social and economic inequities create barriers to good health in many communities.

It is critical that we modernize public health data infrastructure, grow and diversify the public health workforce, invest in health promotion and prevention programs, and reduce health inequities. Investments in public health should be particularly directed to those communities, which due to the impacts of structural racism, poverty, discrimination, and disinvestment are at greatest risk during a health emergency,” said Dr. J. Nadine Gracia, M.D., MSCE, President and CEO to Trust for America’s Health.

Emergency funding is not sufficient to address system weaknesses created by chronic underfunding

State and local public health agencies managed two divergent realities during the COVID-19 pandemic. Short-term funding was up significantly as the federal government provided funding to states and localities in an effort to control the virus. But this funding was one-time money and often specifically tied to COVID-19. Most of it could not be used to address longstanding deficits in the public health system, including ensuring the provision of basic public health services, replacing antiquated data systems, and growing the public health workforce. An October 2021 analysis conducted by the de Beaumont Foundation and the Public Health National Center for Innovations, found that state and local health departments need an 80 percent increase in the size of their workforce to be able to provide comprehensive public health services to their communities.

Funding for two key emergency preparedness and response programs are down sharply over the past two decades:

  • The U.S. Centers for Disease Control and Prevention (CDC) is the country’s leading public health agency and the primary source of funding for state, local, tribal, and territorial health departments. CDC’s annual funding for Public Health Emergency Preparedness (PHEP) programs increased slightly between FY 2021 and FY 2022, from $840 million to $862 million, but has been reduced by just over one-fifth since FY 2002, or approximately in half when adjusted for inflation.
  • The Hospital Preparedness Program, administered by the U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Preparedness and Response, is the primary source of federal funding to help healthcare systems prepare for emergencies. It has experienced a nearly two-thirds reduction over the last two decades when adjusted for inflation.

Funding for health promotion, prevention, and equity also need sustained growth

As a nation, we spent $4.1 trillion on health in 2020 but only 5.4 percent of that spending targeted public health and prevention. Notably, this share nearly doubled last year as compared to 2019 – due to short term COVID-19 response funding – but is still grossly inadequate and likely to return to pre-pandemic levels if the historic pattern of surging funding for public health during an emergency but neglecting it at other times resumes. Inadequate funding means that effective public health programs, such as those to prevent suicide, obesity, and environmental health threats, only reach a fraction of states. This longstanding neglect contributes to high rates of chronic disease and persistent health inequities.

Recommendations for policy actions

The report calls for policy action by the administration, Congress, and state and local officials within four areas:

Substantially increase core funding to strengthen public health infrastructure and grow the public health workforce, including increasing CDC’s base appropriation and modernizing the nation’s public health data and disease tracking systems.

Invest in the nation’s health security by increasing funding for public health emergency preparedness including within the healthcare system, improving immunization infrastructure, and addressing the impact of climate change.

Address health inequities and their impact on root causes of disease by addressing the social determinants of health that have an outsized impact on health outcomes.

Safeguard and improve health across the lifespan. Many programs that promote health and prevent the leading causes of disease, disability, and death have been long neglected and do not reach all states or the populations most as risk. Reinvigorating programs that stem chronic disease, support children and families, and prevent substance misuse and suicide should be a top priority.

Read the full report