Public health's progress stalls in 2017

In 2017, public health advocates sat on a seesaw of sorts.

After being promoted as a possible solution to drug abuse and chronic illness, public health was poised to go beyond the traditional function of protecting against infectious disease and foodborne illness. Addressing poverty, unemployment and violence as a means to better health caught the attention of providers, lawmakers and regulators alike.

But then, as healthcare fell in the crosshairs of a GOP-controlled Congress focused on repealing the Affordable Care Act, programs aimed at expanding public health's scope lost funding and support.

"It's like a tale of two years," said Edward Hunter, president and CEO of the de Beaumont Foundation, an organization that supports local and state public health programs. "On the one hand, I think the conversation has kind of grown outward."

On the other hand, Hunter said, the political environment this year made public health providers and advocates worry about properly funding campaigns to end drug abuse and abate the health effects of climate change, as well as maintain resources to handle their traditional core functions.

In May, the White House released its first fiscal budget proposal that included major cuts to the Centers for Disease Control and Prevention and programs to prevent HIV/AIDS, hepatitis, sexually transmitted infections and tuberculosis.

President Donald Trump's budget included a $65 million cut to the CDC's efforts to track and prevent foodborne illnesses, vector-borne diseases such as Zika, and hospital-acquired infections such as antimicrobial-resistant pathogens.

The draft budget also called for $136 million to be cut from the CDC's disaster preparedness and response efforts. Those funding cuts will only make it more difficult to respond to hurricanes like Harvey or Maria if they strike in 2018, experts say.

While hurricanes and other natural disasters have challenged many administrations, this White House has taken actions that some scientists say have worsened environmental challenges.

One of the Trump administration's first actions was to pull verbiage referring to climate change from some federal websites. Shortly after, the CDC canceled a climate change conference.

Research shows that climate change significantly amplifies public health risks. Warmer global temperatures cause more frequent extreme weather events, such as heat waves, droughts, floods and hurricanes. Those weather conditions make people more susceptible to heart problems, stroke and infectious diseases. Burning fossil fuels also leads to more air pollution, one of the most common causes of respiratory conditions and premature death.

In March, Trump signed an executive order to eliminate the Clean Power Plan, an Obama-era environmental rule that aimed to reduce carbon emissions from power plants by 32% below 2005 levels by 2030.

Months later Trump announced plans to pull out of the Paris climate accord, in which the U.S. had agreed to reduce its greenhouse gas emissions by as much as 28% below 2005 levels by 2025.

Dr. Georges Benjamin, executive director for the American Public Health Association who was involved in the CDC's climate change conference, said his colleagues were aware that the Trump administration wasn't going to support climate change abatement efforts and therefore pre-emptively canceled the event.

He and other public health advocates have warned that efforts to repeal the ACA and cut funding to Medicaid could result in millions of people losing mental healthcare coverage. The Children's Health Insurance Program, which covers 9 million children and millions of pregnant women, and federal funding for community health centers were both lost on Oct. 1. Many states and community healthcare centers have run out of money and have begun to implement cuts amid much uncertainty for programs with significant bipartisan support but are stymied by political infighting.

"The status of the infrastructure for the public health system in the country continues to degenerate at a rapid rate," Benjamin said.

In mid-December, CHIP received a temporary reprieve when Congress passed nearly $3 billion to extend it until the end of March.

The bill also provides $550 million for community health centers, which are the point of care for 27 million people but which are suffering now because their $3.6 billion in annual federal funding hasn't been renewed by Congress. That undelivered federal funding makes up nearly 20% of total annual revenue for community centers, which had been able to expand their preventive services and increase access over the past decade thanks to more insured patients through Medicaid expansion and the Affordable Care Act. But the temporary funding would come by redirecting $750 million from the ACA's public health and prevention fund, which makes up roughly 12% of the CDC's annual budget. More than 60,000 healthcare jobs could be lost if funding is not fully restored.

Such funding uncertainties defined public health in 2017. Even as public consensus grew even louder for action to address issues such as drug abuse and climate change, government budgetary priorities seemed at times to move such efforts in the opposite direction.

In March, Trump formed a special task force led by New Jersey Gov. Chris Christie to identify and recommend evidence-based solutions and in August announced plans to declare the opioid crisis a national emergency. But there was no funding to support front line health workers.

Shortly after, Trump proposed cutting $400 million from the Substance Abuse and Mental Health Services Administration, including $73 million less for substance abuse prevention efforts.

"We've seen all talk, no action," said Lindsey Vuolo, associate director of health law and policy at the National Center on Addiction and Substance Abuse. "We've heard a lot of people speaking very compassionately about the epidemic, many good recommendations have been developed, and we've had the declaration of a public health emergency, but recommendations and declarations alone don't save lives."

Benjamin said the proposed cuts to public health will place the greatest strain on state and local health departments, many of which are already at their capacity to respond to emergencies.

"People are saying they simply don't have the resources to do their job," he said.