Underfunding Public Health Is a Decision to Let People Die in the Next Pandemic

With the COVID-19 pandemic still ongoing and monkeypox now deemed a public health emergency in the U.S., we are now officially in the midst of two viral-disease crises. Public health experts know what it takes to get a disease outbreak under control — widespread identification/testing, treatment and prevention. However, systemic issues with the financing and operation of health care in this country have created a public health system that is reactive instead of proactive. As a result, our public health system is chronically underfunded, understaffed and, in some areas, being stripped of its legal powers.

Key federal public health preparedness and response programs at the U.S. Department of Health and Human Services — including the Centers for Disease Control and Prevention (CDC), the Public Health Emergency Preparedness Cooperative Agreement, the Hospital Preparedness Program, and the Prevention and Public Health Fund — are not getting the resources they need. The CDC budget, a major source of funding for state and local health departments, has only risen by 11 percent over the past decade, after adjusting for inflation. The Public Health Emergency Preparedness Cooperative Agreement and Hospital Preparedness Program have experienced cumulatively budget decreases of 48 percent and 61 percent, respectively, when accounting for inflation between the early 2000s and 2022. These programs experienced an influx of emergency funding in response to the COVID-19 pandemic, yet they were still operating well below pre-pandemic highs. The Prevention and Public Health Fund was established as part of the Affordable Care Act but has faced constant threats from policy makers trying to use it to offset costs for other administration priorities. Meanwhile, funding for state and local health departments has remained flat or declined over the past decade, while the health department workforce shrank 23 percent between 2008 and 2019.

The way in which U.S. health departments are funded contributes to their workforce shortage issues and is one of the reasons why 50,000 public health jobs lost during the Great Recession of 2008 were never replaced. Many departments rely heavily on disease-specific grant funding, creating unstable and time-limited positions. The problem with this type of discretionary funding is multifactorial. It takes time and resources to apply for these grants, which is something most health departments are already lacking. Additionally, because funding is generally limited to use within a single fiscal year, recruitment of qualified personnel is challenging. In the face of comparatively low pay and uncertain funding year-to-year, more and more public health graduates are turning to the private sector for employment.

As it stands, more than 40 percent of public health workers may leave their jobs during the next five years, according to results from the 2021 Public Health Workforce Interests and Needs Survey. While the public health workforce is underpaid and overworked, the politicization of the COVID-19 pandemic response brought with it new issues that contributed to worker burnout, including negative public attention.

Most public health officials have been accustomed to relative anonymity as they went about their work, but in recent times some have had to contend with armed protesters or threats to themselves or personal property. According to a study in the American Journal of Public Health, 57 percent of local health department reported experiencing harassment during the COVID-19 pandemic, which pushed 256 officials to quit between March 2020 and January 2021.

This exodus of skilled public health workers will slowly erode the skills in governmental public health agencies and weaken their ability to respond to future emergencies. This comes at a time when current estimates show state and local public health departments need an 80 percent increase in their workforces to provide the minimum set of public health services (e.g., communicable disease control, chronic disease and injury prevention, assessment and surveillance, policy development and support, etc.) — according to a report from the de Beaumont Foundation. In times of simultaneous public health emergencies, like we are currently experiencing now, even more staffing is needed to provide the necessary “people power” for effective case investigation and contact tracing to slow down disease transmission.

Additionally, many conservative state legislatures are rolling back the authority of public health agencies or officials to institute policies that protect the public’s health. At least 26 states have passed laws limiting public health powers. These have included legislative attempts to undermine the authority of public health agencies to close businesses in the name of public safety, institute mask mandates, vaccine requirements or quarantine infected individuals. Political pressure has also included threats to pull or redirect public health funding. Collectively, this will weaken local, state and national efforts to address the next pandemic.

Unfortunately, public health is often a victim of its own success. No one can see the disasters that are thwarted through preparedness, so it is easy to neglect the invisible. This feeds into a boom-and-bust cycle of public health spending in the face of emergencies.

The purse strings of public health funding are controlled by politicians who are voted into positions of power by the voters. Research has shown that U.S. voters view politicians more favorably for delivering disaster relief spending, like the Coronavirus Aid, Relief, and Economic Security Act, compared to preparedness funding, with a significant relationship between increases in relief spending and additional votes. This incentivizes lawmakers to continue the reactive funding practice.

Monkeypox has shown us that the next pandemic can occur before we have properly controlled the previous one. It is thus imperative that we improve the public health system in this country and better prepare ourselves for yet another pandemic that could strike at any moment.

A more proactive approach to funding public health in this country doesn’t just involve spending more, it also involves changing how we appropriate these funds. One option would be for the government to increase the proportion of public health spending that is mandatory instead of discretionary, which would reduce the year-to-year funding variability that adversely affects state and local health departments.

A second option would be for the government to replace siloed or categorical funding and instead provide more general funds that give public health agencies the flexibility to spend according to their priorities or emerging community needs.

A third option would be for the government to award funding based on a measure of community need, like an “area deprivation index.” Doing so would be more equitable than awarding funding through competitive grant programs, which can further disparities by rewarding agencies with the resources and skills to submit successful grant applications at the expense of those in poor or underserved communities. No single policy can fix public health in this country, but these are some policies that can improve it.