(Washington, DC – May 7, 2021) – Chronic underfunding of the public health system was a key contributing factor in the nation’s flatfooted response to the COVID-19 pandemic, according to a new report, The Impact of Chronic Underfunding on America’s Public Health System: Trends, Risks, and Recommendations, 2021, released today by Trust for America’s Health.
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.
According to the report’s authors, the missteps of the 2020 COVID-19 response were rooted in a public health system weakened by years of underfunding, the federal government’s failure to communicate and follow the best available science, and, health inequities that put communities of color and Tribal Nations at particular risk.
The report also highlights the need for the public health system to be ready to prevent and respond to a spectrum of risks, from weather-related emergencies to the rising number of drug overdoses, to increasing rates of obesity and resulting chronic diseases.
“What the system urgently needs is sustained, predictable funding that allows it to grow and maintain its workforce and invest in modern data systems and all-hazards preparedness planning on a year-in, year-out basis,” said John Auerbach, President and CEO of Trust for America’s Health.
CDC funding down for the year and decade
The Centers for Disease Control and Prevention (CDC) is the primary federal provider of public health funding to states. For FY 2021, CDC’s budget (aside from supplemental COVID response funding) was $7.8 billion, down 1 percent from the previous year, and continues to be insufficient to meet the country’s public health needs. Over the last decade (FY 2012 – 21) the CDC’s core budget fell by 2 percent when adjusted for inflation. That decrease in spending happened over a 10-year period in which the U.S. population grew, the number and severity of weather-related emergencies increased, and the number of Americans grappling with substance abuse, suicide and chronic disease also grew. Anemic funding for CDC has meant that effective programs fail to reach all 50 states, and there has been little investment in cross-cutting infrastructure and capabilities.
CDC’s annual funding for Public Health Emergency Preparedness (PHEP) cooperative agreements, which support core emergency readiness capacity in states, territories and local areas, increased by $20 million in FY 2021. But funding for PHEP shrank by approximating one-quarter (about half when adjusting for inflation) over the last two decades from $939 million in FY 2003 to $695 million in FY 2021.
In addition, the Hospital Preparedness Program, the main source of federal funding to help healthcare systems prepare for emergencies, has experienced a nearly 50 percent funding cut (nearly two-thirds when adjusted for inflation) over the last two decades – from $515 million in FY 2003 to $280 million in FY 2021.
At the state level, 43 states and the District of Columbia maintained or increased their public health funding in FY 2020. In some instances, state-supported COVID response funding increased the state’s public health funding for the year but this emergency response funding is unlikely to translate into sustained funding growth.
Public health workforce is smaller than it was a decade ago
The state and local public health workforce is a critical component of the nation’ public health infrastructure. From 2008 to 2019 the estimated number of full-time local public health agency staff decreased by 16 percent, while state health agencies lost almost 10 percent of their collective workforce between 2012 and 2019. These personnel cuts translated into fewer trained professionals available to do critical work as the COVID-19 pandemic was spreading across the country.
Congress passed numerous COVID relief bills since March 2020, funding that has been critical to managing the immediate crisis. But this one-time funding is not a solution to years of underfunding which hollowed out the system, thereby making it less able to spend emergency funds quickly and efficiently.
The report calls for a $4.5 billion annual investment in the nation's core public health capabilities
Other recommendations highlight the need to:
- Substantially increase core funding to strengthen the public health system, including by building and supporting the workforce, modernizing the system’s data tools and increasing its surveillance capacities.
- Strengthen public health emergency preparedness, including within the healthcare system.
- Safeguard and improve Americans’ health by investing in chronic disease prevention and the prevention of substance misuse and suicide.
- Take steps to advance health equity by combating the impacts of racism and addressing the social determinants that lead to poor health.