The American Health Care Act, which proposes to repeal and replace the Affordable Care Act (ACA), would dismantle the Prevention and Public Health Fund (PPHF). States received over $625 million from the PPHF in fiscal year 2016,[i] and stand to lose more than $3 billion over five years if it is repealed.[ii] The bill would repeal all new appropriations for the PPHF starting in fiscal year 2019, and rescind any funds left over at the end of 2018.
States could lose $160 million per year from the Preventive Health and Health Services (PHHS) Block Grant, which has been entirely funded by the PPHF since 2014.[iii] The Block Grant awards funds to all 50 states and the District of Columbia to support state public health infrastructure, respond to emerging public health issues, and address the health priorities of states in “innovative and locally defined ways.” Although the Block Grant existed prior to the creation of the PPHF, it now relies wholly on it for funding.
Eliminating the PPHF could also hamper state efforts to respond to the opioid crisis. As states work to respond to increasing numbers of deaths from drug overdoses, state public health departments have stepped up prescription drug monitoring programs and other interventions with the support of the Centers for Disease Control and Prevention (CDC). Since 2010, Pennsylvania has received more than $83 million from the PPHF to support opioid prescription monitoring, along with vaccine programs, cancer screenings, infectious disease detection and response, and chronic disease prevention.
- Pennsylvania Secretary of Health Dr. Karen Murphy said, “Repealing the Prevention and Public Health Fund would resonate beyond the federal level and hit state and local health departments hard…The loss of this funding in the coming years arrives at a time when major health threats, like infectious diseases and the opioid epidemic, are on the rise. The PPHF is vital to help protect the health of the nearly 13 million people who call Pennsylvania home.”
States also rely on the PPHF to help them keep children and families healthy. Louisiana depends on $9 million annually from the PPHF to support programs such as lead testing for children and home visits for low-income pregnant women and new mothers, which reduce premature births, according to Louisiana Secretary of Health Dr. Rebekah Gee. In 2016, $17 million in PPHF funding helped states reduce childhood lead exposures and conduct blood-lead testing and surveillance. Those funds helped states respond to disease outbreaks such as the flu and measles, as well as bolster their immunization infrastructure.
Virginia received just under $10 million in 2016 from the PPHF, including funds to fight heart disease and stroke, immunize children, and reduce health disparities and premature deaths, according to one report. Virginia State Health Commissioner Dr. Marissa J. Levine was quoted as saying that if all of ACA repeal goes forward, “we could pretty rapidly lose about $27 million like that.” Over $324 million in the CDC immunization funds that support states would be jeopardized by a dismantling of the PPHF.
States could also lose $40 million from the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Cooperative Agreement if the PPHF is abolished by the American Health Care Act. The ELC also gave cities and states an additional $60 million in July 2016 to fight Zika. The ELC, which receives over 40 percent of its funding from the PPHF, enhances state laboratory and epidemiological capacity and supports state health information technology infrastructure. The ELC also funds state efforts to address tick-borne diseases, influenza, drug-resistant infections, foodborne illness, and hospital-acquired infections, among others. It also helped pay for more than 1,000 jobs in state and local health departments. [iv]
What can we learn from states?
Recent state experience illustrates what is at stake in conversations about reducing federal support for state public health infrastructure. The 2016 Zika crisis stretched to capacity the existing disease surveillance and response infrastructure of some states. Florida relied on additional support from the CDC to speed up the processing of laboratory testing for the Zika virus by providing thousands of test kits and seven laboratory technicians to help process them. Texas received scientific expertise, cross-state coordination, and a $5 million grant from the CDC’s supplemental Zika funding approved by Congress to combat the disease. The state also received Zika response funding from the PPHF.
Even when states are meticulously efficient stewards of resources, the ability of state public health agencies to respond to crises may be compromised if the American Health Care Act takes away the PPHF funding from states and the CDC. Responding to outbreaks and new infectious diseases is a matter of fiscal as well as public health: Infectious diseases cost the U. S. more than $120 billion per year, yet funding for core public health preparedness and response has been cut by more than one-third in the last 10 years.[v]
Questions for policymakers
- What public health functions will states have to cut or scale back if the PPHF is eliminated? Would state cuts lead to a failure to reduce drug overdoses, injuries, or infectious, chronic, and/or vaccine-preventable diseases?
- Would state cuts to public health programs lead to greater expenditures by Medicaid, criminal justice, or other state agencies? If so, how can those expenditures be quantified and budgeted for?
- Will the PHHS Block Grant be discontinued if the PPHF goes away? Or will the Block Grant be continued with a different federal funding source? If so, what will be the source of funding? How would funding levels change?
- Will states be able to afford to use general fund dollars to make up for the loss of federal prevention funding? What other state funding will be cut to make up the difference?
The ACA created the PPHF to fund both new prevention programs as well as programs that predated it. As the House bill to repeal and replace the ACA and eliminate the PPHF moves through Congress, policymakers should reflect on the impact of its repeal on states. There is much to learn from states stretched thin by responding to infectious diseases and the opioid crisis at the same time as battling preventable diseases and chronic conditions. We see what happens when under-resourced states are called upon to respond to extraordinary events; what will we see if robust federal help is no longer available to states? What do policymakers need to protect states’ ability to safeguard the health of their residents?
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation.
[i] U. S. Centers for Disease Control and Prevention (CDC), “Accomplishing CDC’s Mission with Investments from the Prevention & Public Health Fund, FY 2010-FY 2016,” https://www.cdc.gov/funding/documents/cdc-pphf-funding-impact.pdf
[ii] Trust for America’s Health (TFAH), “Special Analysis: Prevention and Public Health Fund Federal & State Allocations,” January 2017, https://tfah.org/reports/prevention-fund-state-facts-2017/