Public Health Will Pay the Price of Debt Limit Deal, Experts Warn

By Jonathan LambertMay 31, 2023

Full article on The Messenger.

he debt ceiling deal negotiated by President Biden and House Speaker Kevin McCarthy (R-Calif.) could undermine efforts to bolster the United States’ flagging public health system and leave the country less prepared to deal with future threats.

The bill would claw back nearly $30 billion in unspent COVID-19 aid from roughly $4 trillion approved over the past three years. Losers would include programs to recruit more public health personnel – exacerbating shortages made worse by the pandemic – and to improve global monitoring and data sharing of potentially dangerous viruses. And because the deal would also cap spending for the next two years amid significant inflation, it would effectively cut funding for federal public health programs going forward.

The House could vote on the measure as soon as Wednesday, sending it to the Senate ahead of a June 5 deadline.

“It may seem reasonable to rescind that money because the COVID emergency is over, but when you look under the hood, there’s a lot of important work that still needs to be done that would stop if this money is taken back,” said Adriane Casalotti, chief of government and public affairs for the National Association of County and City Health Officials.

Boom and bust

Much of this unspent money was intended “to strengthen the system writ large so we’re better off moving forward,” she said – even beyond COVID.

Gaps in the U.S. public health system appeared early in the pandemic, as authorities struggled to make tests widely available and to find effective treatments for the virus and monitor its spread on a national, state and local level. Well into the crisis, some public health departments were sharing information via fax machine. The debt-limit deal would reclaim relief money Congress had approved to help fix those problems and others.

“We have a strong history of boom and bust funding in public health,” said Casalotti. “A crisis emerges, and funding and attention follow. But as soon as it fades from the headlines, so do those resources, and we’re back at square one.”

While the federal government has spent much of the $4 trillion in COVID relief approved during the pandemic, many agencies have held some money back, given the dynamic nature of the crisis, said Carolyn Mullen, senior vice president of government affairs and public relations at the Association of State and Territorial Health Officials.

“Agencies wanted to make sure that some of those funds would be available so that they could more thoughtfully distribute it,” as needs changed, she said. Although the federal public health emergency for COVID ended on May 11, the virus is still killing hundreds of people a day.

Experts are still trying to figure out the precise impact of the debt-limit deal. The agreement would spare a few programs the White House deemed crucial, including $5 billion for efforts to develop variant-proof vaccines and treatments, as well as money to give COVID-19 vaccines to uninsured people. But the rest is harder to parse, since it’s unclear to many how much money is left in the various funding buckets set up by pandemic-era bills

Efforts to bolster the public health workforce could dry up

One of the clearest impacts of the debt-limit deal would be to cut off all unobligated money devoted to hiring and maintaining more public health workers – up to $350 million.

“That might not seem like a lot, but that is a lot of money for local public health departments,” said Casalotti.

The U.S. public health workforce was stretched thin even before the pandemic, having shrunk by more than 20 percent from 2009 to 2019 from underfunding. COVID relief money helped temporarily bolster the workforce, allowing public health offices to track the virus’ spread, carry out contact tracing, distribute vaccines and more. But burnout and harassment are driving workers away, threatening to leave the nation’s public health agencies worse off than they were before COVID hit.

“Losing any of those dollars can have a large effect on our ability to attract and retain the best people in those positions ready to go to keep us safe,” said Casalotti. An analysis by Casalotti’s team found that a public health workforce loan repayment program with $200 million in funding would be enough to support two additional workers in every public health department across the country.

Fewer public health workers means less capacity to deal with all infectious diseases, from COVID-19 to influenza, and diminished ability to respond to the opioid crisis and the uptick in sexually transmitted diseases seen during the pandemic. The debt limit legislation has emerged as federal authorities are warning that monkeypox, which emerged as a new viral threat last year worldwide, is poised for a resurgence in the U.S.

Centers for Disease Control and Prevention would lose nearly $2 billion

The bill would rescind about $1.7 billion from the CDC, which is about half of what Mullen initially expected. There’s some good news: The legislation largely spares relief money for efforts to identify new variants through genomic surveillance, as well as systems that monitor vaccine safety and effectiveness.

Still, “losing $1.7 billion from CDC being rescinded is a missed opportunity and a disappointment, because we could have used those funds to ensure that we’re better prepared for the next pandemic,” said Mullen.

The bill would also claw back money from programs aiming to increase trust in vaccines, for instance, and could hamper agency-wide efforts to modernize data collection and infrastructure by taking away money from a CDC general fund, though money explicitly allocated to those programs appears safe.

The deal would roughly halve available funding for the CDC’s Rapid Response Reserve Fund, said Casalotti, “whose sole purpose is to exist so that if there is a problem, you can respond early.”

Deal would hobble research into other pandemic threats

All remaining relief funds for the National Institutes of Allergy and Infectious Diseases’ research into non-COVID-19 pandemic threats, including research into other coronaviruses and pandemic flu, would be rescinded. The agency, part of the National Institutes of Health, has become a target of ire for Republicans in the pandemic era – motivated in large part by animus toward its former chief, Anthony Fauci, who retired late last year.

“The notion that we had just gone through a pandemic, and [only to] then eliminate research to prepare for future coronavirus pandemics just makes no sense,” said Ellie Dehoney, Senior Vice President of Policy and Advocacy at Research!America, a health-research advocacy group. While the amount of money being rescinded is less than other programs, Dehoney does worry about the impact spending caps could have on biomedical research in the next two years, especially given high inflation.

Key programs would be spared – but the overall picture is cloudy

When the dust of negotiations finally settled, the deal was not as bad as many experts feared during negotiations – when House Republicans proposed rescinding up to $60 billion in unspent COVID funds. The final agreement spared several key programs, most notably:

Still, the shift back towards a “bust” period of funding for public health frustrates and worries many experts. Given compounding threats to public health, from COVID-19 to the next pandemic, “our nation needs to put the pedal to the metal,” said Dehoney. “Instead, it sounds like we’re going to be treading water.”