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ASHINGTON — Republicans are intent on repealing a public health fund created by the Affordable Care Act — but with President Trump also pursuing a dramatic reduction in domestic spending, lawmakers admit they don’t know if they could make up the losses at one of the nation’s most critical health agencies.

The latest version of the GOP health care bill would end the law’s Prevention and Public Health Fund, which provides nearly $1 billion annually, in 2019. Those dollars have become an integral part of the Centers for Disease Control and Prevention’s budget, accounting for one-eighth of its funding and providing more than $300 million for immunizations alone.

Assuming the fund is repealed, the CDC would have a big hole to fill. But Trump has also signaled he wants to boost defense spending and reduce spending for domestic programs by the same amount, potentially more than $50 billion.

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Congressman Tom Cole, a Republican who leads a key panel that oversees CDC’s budget, said it was “too early to tell” what would happen or whether his party could do anything to make the agency’s funding whole. He was waiting for more specific direction from the administration.

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“Until we actually get a top-line number, we’re not in a position to rule anything in or out,” he told STAT last week.

But he later acknowledged that, given the scope of the cuts being considered, almost every agency would likely be affected. “If that happened, everybody is going to be impacted.”

The Oklahoma congressman warned of the consequences of deep cuts to CDC, even if he is at the same time supportive of increased defense spending.

“What CDC does is probably more important to the average American than, in a sense, the Defense Department,” he said. “You’re much more likely to be killed in a pandemic than you are in a terrorist attack, so you need to look at it that way. Those investments are extraordinarily important for the protection of the country.”

The prevention fund, created in 2010 by the ACA, provided $932 million for public health programs in 2016.

The CDC received almost all of it, $891 million, or 12 percent of its overall budget. The funds included $324 million for immunization programs, $160 million in block grants for preventive health services, and $126 million for awareness programs focused on the harms of tobacco use.

Nonetheless, other Republicans are happy to get rid of the prevention fund, long a target of their criticism. Whether the latest version of the health care bill sees more changes or becomes law as written, the fund seems beyond saving.

“Look, it’s a slush fund,” said Congressman Andy Harris of Maryland, a Republican physician who sits on the House appropriations health subcommittee. “It’s been used by the secretary [of health and human services] for whatever the secretary wants. It’s a misnomer to call it the Prevention and Public Health Fund, because it’s been used for other things, and it’s about time we eliminated it.”

“You’re much more likely to be killed in a pandemic than you are in a terrorist attack, so you need to look at it that way.”

Representative Tom Cole

Like Cole, Harris left open the possibility of filling the funding gap, though at the same time, he suggested states — which are often the recipients of the CDC’s grants — might need to pick up some of the slack.

“If you want to put money into the CDC or somewhere else, put it into the CDC or somewhere else,” Harris said. “At some point, we have to say that it’s not unreasonable to turn over some of these costs to the states, because they’re not running a deficit, and we are.”

A CDC spokesperson declined to comment, saying the agency cannot speculate about the impact of repealing the fund until it has a budget.

The vast majority of the health care debate so far has focused on health insurance, which has led public health groups to sound the alarm.

The Association of State and Territorial Health Officials sent a letter to congressional leadership in January warning of the consequences for its repeal. The Trust for America’s Health followed up with its own statement after Politico published an early version of the legislation that confirmed fears about the fund’s elimination.

“We were concerned that core public health funding — the PPHF and other good public health elements in the ACA — might get thrown out, a baby with the bathwater kind of thing,” said ASTHO’s executive director, Mike Fraser. “There’s so much more to ACA than just health insurance.”

ASTHO leaders had already planned a lobbying trip to Washington for early March, and now will spend two days in the capital this week urging Congress to make up for lost health care funding either through a long-shot effort to preserve the fund or smaller measures to make up for individual items that are cut.

Other public health advocates worry that the prevention fund cuts are the tip of the iceberg, and that agency budgets beyond just prevention fund dollars are also at risk.

“Until somebody tells us otherwise,” said Richard Hamburg, an executive vice president at TFAH, “if close to $1 billion per year [in prevention fund money] is threatened and we’re hearing that the defense discretionary budget may be an increase of 10 percent, one would have to assume there’d be some across-the-board-cuts in other agencies.”

Dylan Scott contributed reporting.

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