Funding Realities & Emergency Preparedness: A Grim Outlook

“The sky is falling” is no longer just a Chicken Little reference – but, rather, a timely warning about the state of U.S. public health emergency preparedness initiatives in the face of recent large-scale funding cuts by the federal government that may well continue for the foreseeable future.

Following the anthrax attacks in 2001 that created a near panic shortly after the 9/11 terrorist attacks on the World Trade Center towers and the Pentagon – and with the recognition that all responses to public health emergencies begin at the local level – Congress appropriated the funding needed by the Centers for Disease Control and Prevention (CDC) to improve the disaster preparedness capabilities of public health departments nationwide – at all levels of government. This dedicated funding – distributed in the form of Public Health Emergency Preparedness (PHEP) grants – was and is specifically intended for use by states, territories, and major U.S. cities throughout the nation. In most cases, the funding is provided to states and then distributed to local jurisdictions.

Included in the PHEP cooperative agreements is funding for the Cities Readiness Initiative (CRI), which helps state and local jurisdictions draw emergency medical supplies from the CDC’s Strategic National Stockpile (SNS). This program focuses on enhancing preparedness for response to large-scale bioterrorist events by providing such supplies, within 48 hours or less after an official request is made, to the nation’s largest cities and metropolitan statistical areas, where more than half of the U.S. population lives.

Between 2001 and 2008, there was a steady decline in the funding available from the CDC’s PHEP cooperative-agreement allocation to support public health preparedness activities in state and local health departments. Meanwhile, the demands on public health emergency preparedness planning, preparedness, and response capabilities and workloads continued to increase. In fact, according to the CDC, PHEP funding declined from $970 million in Fiscal Year 2003 (FY03) to $689 million in FY09.

Preserving Capabilities, Protecting the Core, Preparing for the Worst 

As one example of how this decline affected readiness, the CDC distributed $325 million of emergency supplementary funding in FY07 that was specifically earmarked for pandemic influenza preparedness activities. Two years later, though, in FY09, not only was there a lack of new funding for pandemic influenza, but overall PHEP funding – which may have been used to cover at least some pandemic influenza initiatives – also declined.

Nonetheless, federal funding is still the core source of financial support for the public heath preparedness programs of many local health departments (LHDs). In 2007, the National Association of County and City Health Officials (NACCHO) pointed out that 41 percent of all state and local health departments that received funding from the CDC’s PHEP grants reported that those funds comprised 100 percent of their budgets for preparedness activities – significantly including the cost of dedicated emergency preparedness staffing. A 2009 NACCHO follow-up survey indicated that, at approximately 68 percent of LHDs, the CDC’s PHEP cooperative agreement funds constituted 90 percent or more of their preparedness budgets.

The LHD preparedness programs have received some additional, but limited, support from other sources of funding – unfortunately, those funds also have been declining. In 2007, 46 percent of the nation’s LHDs reported receiving at least some financial support from local, city, or county funds; that percentage dropped to 29 percent in 2009, however, and continues to decrease. Further complicating the picture is that several media reports indicate that state and local budgets for public health also have diminished significantly in recent years – primarily, it seems, because of the nation’s overall economic decline.

Focusing on the Present – But Forgetting the Future? 

One of the tangential but nonetheless critical issues related to healthcare funding is the need to fund the so-called “disease du jour.” An ongoing pattern of ramping up funding for an emerging public health threat, therefore encouraging the development of additional internal structures and services, then later withdrawing access to federal support, is having a particularly harmful effect on preparedness. One of the best examples of this process of fiscal “management by crisis” can be found in the reaction to improving preparedness, at all levels of government, to cope with a pandemic influenza. In December 2005, Congress appropriated $350 million for overall pandemic influenza planning and response efforts on the part of state and local health departments, and allocated an additional $250 million to that fund in June 2006. Additional funds were made available in fiscal years 2007 and 2008 – but Congress abruptly discontinued that funding stream in FY09.

In FY10, though, Congress approved a $7.65 billion emergency supplemental appropriation for pandemic influenza response activities. Included in that total was $350 million for state and local health departments. This legislation was in large part a positive response to advocacy efforts that stressed the need to support the capabilities of state and local health departments to prepare effectively for, and respond to, the then-ongoing H1N1 influenza pandemic.

On an operational level, these funds were allocated to various initiatives related to H1N1 and, in retrospect, seem to have helped immeasurably in numerous state and local response efforts. However, considered at a more strategic long-term level, such irregular supplemental appropriations are not sufficient to maintain local public health preparedness and response capabilities in the long term, especially when almost all health departments, no matter what their size, rely heavily on regular federal funding to support permanent staff positions.

According to a December 2011 report – Ready or Not? Protecting the Public from Diseases, Disasters, and Bioterrorism – issued by the Trust for America’s Health (a private-sector health policy organization), the cutbacks in this vital element of public health systems are occurring on three levels – state, local, and federal. Following are some of the particulars:

• State Cuts: 33 states (plus Washington, D.C.) cut funding for public health from FY09 to FY10. Of these jurisdictions, 18 were cutting public health preparedness funding for the second year in a row;
• Local Cuts: In January 2010, 53 percent of the nation’s LHDs reported that their core funding had been reduced from the previous year, and an even higher percentage anticipated additional cuts in FY11; the local cuts have resulted in a weakening of the nation’s overall “boots on the ground” public health infrastructure – best exemplified, perhaps, by the loss of approximately 23,000 jobs, or approximately 15 percent of the local public health workforces, since January 2008; and
• Federal Cuts: Since FY05, federal support for public health preparedness programs has been reduced by 27 percent.

“At Risk”: The CRI, State Labs & Essential Field Officers 

The same reportentified a number of key programs considered to be “at risk” because of the continued cuts in federal public health emergency preparedness funds. More specifically:

(a) Of the 72 cities participating in the Cities Readiness Initiative (CRI), 51 are now at risk of being cut from a program that supports the ability of cities to rapidly distribute and administer vaccines and medications to a large number of people during unforeseen emergencies;

(b) All 10 of the state laboratories currently possessing “Level 1” chemical testing capabilities are at risk of losing their top-level status, a downgrade that would leave the CDC itself with the only public health laboratory in the country possessing the full ability to test for chemical terrorism and accidents; and

(c) There are 24 states also at risk of losing the support provided by Career Epidemiology Field Officers – i.e., CDC experts assigned to various state health departments to supplement state and local efforts to prepare for and respond to various disease outbreaks and other medical disasters.

Clearly, public health agencies and facilities across the country play a critical role in the nation’s overall emergency preparedness and response capabilities. That role has grown even more important since the 2001 anthrax attacks as well as, in the decade since, numerous natural disasters, food-borne outbreaks, and other major public health emergencies (e.g., SARS and H1N1) that have been in the headlines in recent years. Local and state health departments are, in fact, better prepared for emergencies now than ever before in the nation’s history. Since 2001, state and local preparedness capabilities have improved, both consistently and significantly, in such areas as mass vaccinations and prophylaxis planning, all-hazards preparedness training, implementation of the National Incident Management System and Incident Command System, and the installation and use of new or upgraded communication systems.

However, the lack of adequate funding, on a continuing basis, for these and other important programs remains a major concern for emergency planners. Decreases in federal financial support for public health preparedness programs already have resulted in significant staff layoffs. In addition, many state and local health departments are having difficulty managing their budgets, hiring and training staff, and conducting long-term strategic planning under the conditions of unpredictable fluctuations in funding.

Real-World Realities & Other Inconveniences 

More specifically: According to NACCHO, 55 percent of the nation’s LHDs reduced or eliminated at least one program between July 2010 and June 2011, and 20 percent of these programs were in or related to emergency preparedness. In addition, 53 percent of all health departments have experienced some type of negative job impact (e.g., furloughing of employees and/or an overall reduction of hours); this also reduces overall readiness. A continuation of this state of decline will have major implications for public health emergency preparedness efforts and may well result in a decrease in training efforts, an inability to drill or exercise, and/or simply a lack of the resources needed to support the real-world public health emergency responses looming just over the horizon.

The federal partners of state and local jurisdictions also are not immune to these long-running fiscal constraints. Since 2005, the CDC has seen its budgets for preparedness and response slashed by more than $350 million (to the current, FY11, levels of about $832 million). This significant cutback in funding directly, and adversely, challenges the CDC’s own ability to respond to pandemics and other public health emergencies.

The future of the nation’s health preparedness funding is, in short, uncertain – at best. The current outlook for potentially massive reductions in all federal grant funding streams – combined with state and local budget cuts – could have a huge, and harmful, impact on PHEP programs and activities across the board, and at all levels of government. Merely maintaining the current health preparedness capabilities requires not only flexible and sustained federal funding but also the ability, and statutory authority, to hire and train a large number of additional public health professionals in order to reap the benefits that have been built into the system in recent years. In short, without a strong national commitment, U.S. public health may quickly lose the capacity needed to meet current and future homeland security goals. In times of crisis, any reduction in capabilities caused by underfunding public health opens the nation to overburdened healthcare systems, overwhelmed response systems, and overloaded communication systems.

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For additional information on: The 2010 CDC Report

The 2007 NACCHO Report, “Federal Funding for Public Health Emergency Preparedness: Implications and Ongoing Issues for Local Health Departments”

The 2011 NACCHO Survey

The 2011 report from the Trust for Americas Health