Chronic Underinvestment and Recent Disruptions Have Weakened U.S. Public Health System

America’s public health system is at an inflection point. Decades of chronic underinvestment, compounded by workforce reductions, funding disruptions, and institutional uncertainty during 2025 and 2026, have weakened the system’s capacity to protect communities from preventable disease and injury.

The report, Underfunded and Under Strain: The State of America’s Public Health System, calls for restoring federal public health operating capacity and establishing more durable and predictable funding to ensure that public health agencies have the staffing, expertise, infrastructure, and continuity needed to carry out their missions effectively.

TFAH’s report examines the structural conditions that shaped the public health system, the disruptions that followed, and how those changes affected state and local health agencies and communities. It explains how Congress responded, the limits of that response, and why a funded program on paper is not necessarily a fully functioning program in practice. The report also analyzes the FY 2027 proposals and provides recommendations for restoring capacity and establishing a more durable public health foundation.

The public health system is a network of agencies, organizations, public health workers, and community programs working together to prevent illness and injury, promote health, and respond to health threats—helping people and communities live healthier, safer lives.

The report finds that the system entered 2025 with longstanding funding, workforce, and infrastructure vulnerabilities that left it with little margin to absorb additional disruption. In 2024, only about 3 percent of the nation’s $5.3 trillion in health expenditures went to governmental public health activities.

Congress preserved much of the federal public health system in fiscal year (FY) 2026, but appropriations alone could not restore lost operating capacity.

The Consolidated Appropriations Act, 2026 maintained the Centers for Disease Control and Prevention’s (CDC) program-level funding at approximately $9.1 billion—essentially flat with FY 2025—and rejected many of the administration’s deepest proposed cuts while preserving core agency structures. But by May 2026, CDC’s workforce had fallen by approximately 3,600 from the end of FY 2024, a reduction of roughly 28 percent. Grant interruptions, funding delays, and diminished technical and administrative capacity also continued to affect program operations.

The result illustrates a central finding of the report: appropriated dollars are critical, but they are not sufficient to ensure that public health programs can function effectively. Staffing, institutional expertise, grant-administration capacity, technical assistance, stable relationships with grantees, and timely disbursement of funds all help determine whether appropriations translate into services and protections for communities.

“We have a public health system that was already under strain, and workforce, funding, and institutional disruptions have intensified that strain,” said Dr. J. Nadine Gracia, President and CEO of TFAH. “We need predictable and reliable funding, along with sufficient staffing and expertise, to restore capacity and establish a more durable public health foundation that supports the health and well-being of all people and prepares the nation for future public health emergencies.”

If enacted, the FY 2027 President’s Budget Request would deepen the erosion of federal public health capacity.

The proposal moderates some elements of the administration’s FY 2026 request but retains its central direction: a smaller federal public health footprint and a narrower and reorganized CDC with less funding and personnel to carry out programs and activities. Although the proposal would maintain or increase funding for selected capabilities, including some aspects of infectious disease surveillance, data modernization, immunization, food safety, and global health, it also would:

• Eliminate the Prevention and Public Health Fund, a dedicated funding stream that supports prevention and public health programs nationwide.
• Consolidate HRSA, SAMHSA, and major CDC programs into a new Administration for a Healthy America with significantly less funding to support program activities, risking disruption to specialized expertise and established partnerships.
• Reduce total resources supporting functions historically housed at CDC and the Agency for Toxic Substances and Disease Registry by approximately $2.86 billion, or 31 percent, even after accounting for funding proposed to follow programs transferred to other HHS components.
• Create a new National Center for Chemicals and Toxins within CDC while reducing funding for the programs proposed to comprise the center by approximately $718 million relative to FY 2026.
• Substantially reduce broad-based prevention and public health capacity, including chronic disease and injury prevention, state and local preparedness, foundational infrastructure, domestic HIV prevention, and several environmental and occupational health functions.

The report cautions that the risk is not limited to enactment of the proposed cuts. Even if Congress again rejects the deepest reductions, continued flat funding, workforce attrition and hiring constraints, grant-administration disruptions, and sustained uncertainty could further erode public health capacity. Reversing that trajectory will require rebuilding capacity, not simply preserving funding levels.

At the same time, demands on the public health system remain high. Measles outbreaks, declining childhood vaccination rates, foodborne outbreaks, extreme heat, mental health and substance use challenges alongside the other current pressures are testing capabilities that depend on a functioning public health infrastructure—including emergency readiness, environmental and workplace protections, chronic disease and injury prevention, and the capacity of less-resourced communities to prepare for and respond to health threats. These capabilities also support the nation’s economic and national security.

Interviews with On-the-Ground Experts

The report features interviews with two public health officials—Dr. Daniel Edney, State Health Officer of Mississippi, and Dr. Michelle Taylor, Commissioner of Health for the Baltimore City Health Department—who describe what federal funding and operational uncertainty have meant on the front lines.

Policy Recommendations for Protecting the Nation’s Health, Economic and National Security

To protect the nation’s health, economic security, and national security, the report recommends that Congress and the administration take steps to restore and strengthen the public health system, including:

• Restore federal health agency operating capacity. Rebuild staffing, expertise, grant administration, technical assistance, and other operational capacity needed to carry out funded programs and statutory responsibilities.
• Preserve complementary federal capabilities. Preserve and strengthen the distinct roles of CDC, the Substance Abuse and Mental Health Services Administration, the Health Resources and Services Administration, the Administration for Community Living, the Administration for Strategic Preparedness and Response, and other federal health agencies. Major restructuring should proceed only through a bipartisan, deliberative process with congressional oversight and stakeholder input.
• Strengthen CDC as a comprehensive national public health agency. Provide at least $11.58 billion for CDC in FY 2027, followed by sustained increases, and preserve its responsibilities across infectious disease, chronic disease, injury prevention, environmental and occupational health, preparedness, and foundational infrastructure.
• Ensure that appropriated funds are spent as intended. Release funds promptly and prevent awards from being delayed or terminated for reasons unrelated to statutory purposes, performance, or compliance.
• Provide durable and predictable financing. Enact full-year appropriations on time, restore and protect the Prevention and Public Health Fund, and reject new discretionary funding caps that hinder public health modernization and readiness for evolving health threats.
• Invest in foundational infrastructure and health security. Sustain workforce, laboratory, epidemiology, data-modernization, and cross-cutting health department capacity, and create a Health Defense Operations budget designation for programs central to the nation’s health, economic, and national security.

Read the full report

 

The Public Health Programs Monitor

In tandem with the report, TFAH has also launched the Public Health Programs Monitor, a nonpartisan initiative with an interactive dashboard that tracks selected federal health-promoting programs and operational activities across HHS. The monitor brings together budget information and proposed and actual program changes, along with analysis that helps explain how federal funding, staffing, and administrative decisions affect public health programs and the communities they serve.