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The agreement to raise the federal debt limit will result in serious setbacks for public health, policy experts say, stalling some efforts to fight outbreaks of infectious diseases and to prepare for future health emergencies.
The deal struck over the weekend between the White House and congressional Republicans suspends the federal debt ceiling until January 2025 and imposes spending caps, holding nondefense spending roughly flat in fiscal year 2024 and limiting spending growth to about 1% the following year. The agreement includes clawbacks of roughly $27 billion in unspent COVID-relief money.
The spending caps “will make it extremely difficult to increase funding for public health in the next two years,” meaning that some critical investments will likely be forgone, said Carolyn Mullen, a senior vice president at the Association of State and Territorial Health Officials.
As for the plan to rescind unspent COVID-relief money, “we think that it is horrific that any COVID funding is getting traded for a debt-ceiling agreement,” said David Harvey, executive director of the National Coalition of STD Directors. That funding, he said, is needed not just for COVID response but to modernize the public-health system and improve its response to infectious-disease outbreaks.
Supporters of the deal note that it takes the threat of a U.S. debt default off the table until the start of 2025 and protects some key healthcare programs, including veterans’ medical care and benefits for veterans who have been exposed to burn pits and other toxic substances. Some pandemic-related priorities such as investment in next-generation vaccines are also expected to be protected. And the deal excludes Medicaid work requirements, which could have caused many enrollees to lose coverage.
The House is expected to vote Wednesday on the bipartisan debt-ceiling package, called the Fiscal Responsibility Act.
Although more details are needed to fully assess its impact on public health, the deal sends one clear message, said Jennifer Kates, senior vice president at KFF, a health-policy nonprofit. From the perspective of policy makers, “the message here is, ‘COVID is over. We’re taking back that money and moving on,’” Kates said.
Building skyscrapers on a shaky foundation
For some health-policy experts, the debt-ceiling agreement brings back bad memories of the 2011 Budget Control Act, which imposed spending caps that crimped public-health investments in subsequent years. As a result, “when the pandemic hit, we were operating from a deficit standpoint,” Mullen said. “We were asked to build skyscrapers when the foundation was really shaky. There had been underinvestments in public-health programs for the last decade.”
Years of dwindling investment in some key public-health programs “does have an impact on the ground,” Mullen said. Funding for the Public Health Emergency Preparedness cooperative agreement, for example, a key source of funding for state and local health departments, has been cut by more than 20% since fiscal year 2003, or roughly 50% after adjusting for inflation, according to a recent report from the nonprofit Trust for America’s Health.
Spending caps included in the debt-ceiling deal also raise concerns about funding for everything from cancer research to the fight against sexually transmitted diseases, policy experts and patient advocates say. The caps “could lead to cuts to cancer research — risking our nation’s current and future progress in the space,” Lisa Lacasse, president of the American Cancer Society Cancer Action Network, said in a statement.
After fighting for several years to get more funding for HIV testing and treatment, Carl Schmid, executive director of the HIV + Hepatitis Policy Institute, said “it looks like those things are going to be on hold, unfortunately, for the next couple of years.” One area where funding is particularly needed, he said, is in improving access to pre-exposure prophylaxis (PrEP), which can help prevent HIV infection. Although annual new HIV infections declined between 2017 and 2021, huge disparities remain in PrEP access. In 2021, for example, only 11% of Black people eligible for PrEP were prescribed the medication, compared with 78% of white people, according to a report released last week by the Centers for Disease Control and Prevention.
More broadly, the spending limits will likely block needed investments in educational and prevention programs for sexually transmitted diseases, in new therapeutics and vaccines and in public-health workers to investigate outbreaks, Harvey said. Reported cases of chlamydia, gonorrhea and syphilis all increased between 2020 and 2021, with cases of congenital syphilis jumping 32% and resulting in 220 stillbirths and infant deaths, according to the CDC.
It’s difficult to pinpoint the precise effects that clawing back unspent COVID-relief money will have, policy experts said, in part because those funds could go have gone toward a vast array of programs. Six laws enacted in 2020 and 2021 provided about $4.6 trillion for pandemic response and recovery, according to the U.S. Government Accountability Office, and as of Jan. 31, about $90 billion remained available. But it’s likely that some of the money to be rescinded from the CDC, for example, could have gone toward data-modernization efforts and surveillance work, Kates said.
“Rescinding these unobligated COVID funds is disappointing,” Mullen said. Congress could have maintained that funding for public health, she said, not only for COVID-response efforts that remain necessary but also for broader critical investments, such as those in data collection and the public-health workforce. Rather than reacting to each emergency as it arises, she said, “it would be far better to look long term and look holistically at public health.”
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