WASHINGTON — Representative Tom Cole, a Republican from Oklahoma, loves the Centers for Disease Control and Prevention. When he’s asked about public health funding, he often recites a favorite factoid: “You’re much more likely to die in a pandemic than in a terrorist attack.”
But before the House passed the American Health Care Act on Thursday, Cole — who chairs the appropriations subcommittee that oversees health spending — would not say how Congress would replace the nearly $1 billion in grants the bill would strip from the CDC and other federal agencies if it becomes law. Those grants, from what’s known as the Prevention and Public Health Fund, made up one-eighth of the CDC’s funding in 2016.
Instead, Cole pivoted back to the bill’s main goal: substantially altering the market for health insurance.
“Let’s just wait and see where we end up,” Cole said of the PPHF before the vote on Thursday. “We’ve shown we’re willing to make substantial investments in this direction, and we have. I’m not going to worry about every part of this bill — I have to actually represent the people in my district who are in this [Affordable Care Act] exchange with a 69-percent rate increase,” referring to premium hikes for some Oklahoma consumers on the federal ACA exchange.
The PPHF, rarely mentioned as the House debated the broader legislation to repeal and replace major elements of the Affordable Care Act, gets portioned out to federal agencies including the CDC, the Substance Abuse and Mental Health Services Administration, and the Administration for Community Living. The PPHF, in existing law, authorizes $900 million in appropriations in 2017 and 2018, then fluctuates for the next five years before jumping to $2 billion in 2025.
Republicans have referred to it as a “slush fund” — a characterization its supporters say might have been fair at its inception but is now misleading given its largely set funding stream to the CDC, SAMHSA, and ACL.
The funds have become an integral part of those agencies’ budgets, providing $932 million in total for public health programs in 2016. The CDC received almost all of it, $891 million, including $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.
The AHCA now heads to the Senate, where Republicans hold just a two-seat advantage, and where the bill will likely undergo substantial changes.
The issue of the prevention fund bubbled up somewhat in March before the House’s initial, failed effort to repeal the ACA. That effort happened to coincide with a Capitol Hill gathering of state health officials who oversee a number of programs that benefit from PPHF money. Many of the public health advocates managed to wrangle meetings with legislative staff.
Senator Mike Enzi of Wyoming, a Republican and chair of the Senate budget committee, told STAT in March that “those people will be taken care of,” but did not specify a funding mechanism. An analysis by the Trust for America’s Health showed that Wyoming could lose $11 million in preventive health program funding over the next five years if the PPHF is repealed.
Lisa Murkowski, a moderate Republican from Alaska, also stressed in March the importance of continued funding for her state, which could lose $20 million in funding over the next five years. And while some Republican appropriators have suggested leaving prevention fund-related costs to the states, Murkowski acknowledged that the legislatures in Alaska and most other states simply don’t have the budget capacity.
The issue, however, was lost in the bigger picture of a health insurance market revamp, said Cole, who called the PPHF repeal an “ancillary effect” of the AHCA to be dealt with in the future.
“CDC and NIH have done exceptionally well under Republican stewardship,” Cole said, “so I would just take a deep breath and relax.”
A CDC spokesperson referred questions about the agency’s future budget outlook to the White House Office of Management and Budget.
Correction: An earlier version of this story misstated the source of an analysis on the impact of the possible repeal of the PPHF.