Sequestration Could Cripple U.S. Public Health

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By Kelly M. Pyrek

Under the Budget Control Act, most federal programs face an across-the-board cut in January 2013 if Congress does not enact a plan before then to reduce the national debt by $1.2 trillion. This inaction, and the resulting sequestration, has serious consequences for public health agencies and public health departments.

In 2011, Congress passed the Budget Control Act (BCA) which established caps on defense and nondefense discretionary programs such as public health, environmental protection, law enforcement, transportation etc., that will reduce this funding by $1 trillion over 10 years. The BCA also created the Joint Select Committee on Deficit Reduction (often referred to as the supercommittee) to come up with a plan to reduce the deficit by another $1.2 trillion over the same decade. In the event the supercommittee failed to come up with a viable plan, the BCA established sequestration as an incentive to force bipartisan compromise. A rigid budgetary tool, sequestration will force automatic, across-the-board cuts of another $1 trillion to nearly all government programs, including public health. Because the supercommittee failed to produce an agreement, sequestration is scheduled to begin on Jan. 2, 2013.

According to a fact sheet from the American Public Health Association the impact of sequestration on nondefense discretionary programs could be significant. Since fiscal year 2010, nondefense discretionary programs have already been cut by 10 percent on average, with some programs cut more than 50 percent. Cuts under sequestration are expected to be in the range of 8 percent to 10 percent to nondefense discretionary programs, including public health. These cuts will truly be across-the-board, with no department or agency control on how the cuts impact individual programs. In total, if Congress and the President fail to act, between fiscal 2010 and 2021, nondefense discretionary programs will have been cut by 20 percent overall. Such indiscriminate cuts threaten the entire range of bipartisan national priorities.

In terms of what this means for public health funding, most of the public health funding at the federal level is discretionary so it will be impacted by sequestration. Cuts of 8 percent to 10 percent to programs funded at the Centers for Disease Control and Prevention (CDC) would mean:
Life-saving immunizations would be denied to 30,000 children and 20,000 adults.
An increase in the number of HIV transmissions by nearly 800, costing the nation more than $250 million due to reduced availability of HIV tests.
Tens of thousands of additional healthcare-associated infections each year would debilitate patients, kill thousands and cost billions in added healthcare costs.
Decreased ability to evaluate and investigate 100-150 multistate outbreaks identified by CDC surveillance networks, including outbreaks of E. coli, salmonella, and norovirus, causing outbreaks to last longer, get bigger and cause more illnesses and deaths before they are controlled.
Reduced number of local health department staff trained in epidemiology, laboratory and outbreak response by 2,500.
Eliminating over 50 intramural and extramural research, translation and outreach projects and grants increasing the economic burden of work-related injuries and illnesses, which is already more than $13 billion annually.

These cuts would be in addition to those already made that have resulted in the loss of 55,000 high-skilled public health jobs and many more positions furloughed. In a report from Sen. Tom Harkin, chairman of the Senate Appropriations Subcommittee on Labor, Health and Human Services, and Education, and Related Agencies, the potential impact of sequestration on nondefense discretionary programs would impact the public health arena in the following ways: 659,476 fewer people would be tested for HIV, 48,845 fewer women would be screened for cancer; and 211,958 fewer children be vaccinated.

Sequestration can still be avoided, but Congress would have to pass a deficit reduction proposal that is acceptable to the administration by January 2013. The Administration has stated repeatedly that it will not accept a plan that only depends on spending cuts and has requested that Congress pass a balanced deficit reduction plan that also increases revenue through tax reform.

As Congress debates, associations are working hard to be heard. Amanda Jezek, government relations director for the Infectious Diseases Society of America (IDSA), points to an 8 percent reduction of the CDC's budget and says the impact would be devastating. "It's a huge amount, particularly when you consider that over the last few years, the CDC's budget has either been cut or flat-funded, so we view sequestration as being on top of the other budgetary hardships that the CDC has had to sustain over the last several years," Jezek says. "People must recognize that when you talk about funding the CDC, it's not just funding what goes on in Atlanta; much of the CDC's budget goes out to state and local public health departments. Although these departments are on the frontlines dealing with outbreaks, they have already lost, in the last few years, about 50,000 jobs at the state and local public health level. To lose more would be tragic -- they are skilled professionals, and we need them when public health emergencies occur."

Jezek emphasizes how sequestration works if it does take effect: "It's not as though Congress says to CDC, here's an 8 percent cut, you figure out how to distribute it -- the agencies are not given that kind of flexibility. It is an 8 percent cut to every budget line, so the CDC can't say, 'Well these programs are of the highest priority so we are going to hold them harmless.'  Even if they could do that, it would be challenging. There is no ability to set priorities, so everything gets cut."

To bring this message home, Jezek asks people to consider the innumerable services that the CDC performs -- whether it's in the spotlight for a major outbreak, or more often than not, working quietly behind the scenes.
"For laypeople not working in public health issues every day I think there is not as much of an appreciation for what the CDC does or what state and local health departments do until you do have something like a meningitis outbreak and all of a sudden, they want the government to be able to respond," she says. "People must realize that Congress can't simply appropriate some emergency funds when something like this happens, you need that infrastructure already in place for that kind of response. That's the message we have been trying to put out there."

The fungal meningitis outbreak has been used as a touchstone for public health awareness by organizations such as the IDSA. In a statement, IDSA president David A. Relman, MD, FIDSA, referred to the Congressional hearings on the outbreak: "IDSA is pleased that both the House and Senate are holding hearings this week on the recent fungal meningitis outbreak associated with contaminated steroid treatments. This infectious disease emergency has underscored the need for the U.S. to maintain a robust, well-funded public health system that is capable of detecting and responding to public health emergencies, such as outbreaks as well as natural disasters like Hurricanes Katrina and Sandy. The Centers for Disease Control and Prevention (CDC), state, and local officials have been working around the clock to respond to the meningitis outbreak, protect the American public, and minimize the number of fatalities. CDC has helped to identify patients at risk of infection; established treatment regimens for those exposed; and communicated with the public, media, clinicians, and other federal, state, and local government agencies. Unfortunately, pending CDC budget cuts threaten the very core of our nations capacity to prepare for and respond to such emergencies. CDC supplies the bulk of preparedness funding to state and local health departments, which are on the front lines of an emergency response and have seen their workforce severely eroded in recent years due to budget cuts. A stable, well-trained workforce and infrastructure must be in place to respond to public health emergenciescapacity and expertise cannot be built overnight. Additional funding cutbacks to public health, either through sequestration or the traditional budget process, would devastate our nation's ability to respond effectively to future public health emergencies."

Adds Jezek, "I think the meningitis outbreak has done a great deal to highlight the importance of public health, and people are seeing that message. Our responsibility now is to make sure that once the outbreak is addressed and media coverage dies down, that people still maintain that focus on how important public health is. There is also some confusion with some areas of public health where people wonder if that is really needed now that we have health reform, and one of those is immunizations some people are saying now that insurance companies are required to cover all of these ACIP-recommended immunizations, so why do we need the CDC's immunizations programs? So, we must explain that while insurance coverage is a very important piece of that puzzle, it does not on its own equal access to coverage. If you look at what's happening with the pertussis outbreaks, you can see that we still have work to do in terms of getting people their immunizations and responding to these outbreaks when they happen."

Jezek says that the IDSA has been partnering with a number of organizations that work in other areas to champion the importance of public health. It is also a member of the Coalition for Health Funding, a nonprofit alliance working to preserve and strengthen public health investments.
"We're meeting with people in the House and the Senate, and I think the Congressional staff do seem to understand that these programs are important. No one wants sequestration to happen, but how we are actually going to get to a point where we have a bill that everyone can agree upon? The level of cooperation between both parties has to increase for that to happen."

Jezek says that associations like the IDSA understand the need to get the nation's fiscal health in order but adds, "We're not saying 'don't reduce the deficit,' we are just saying you can't do it on the backs of healthcare programs. Even if you were to completely eliminate the budgets for all of the HHS agencies, you wouldn't balance the budget just by doing that. So what we have always said is that we need to have a balanced approach; we need to look much more broadly at funding, at revenue, at all of the different areas of spending to be able to address this problem. If you look at what has been done the last few years, a lot of the cuts have been made on non-defense discretionary spending, and not looking at revenue at all -- just what is appropriated annually. We feel as though these programs have already been taking hits year after year;  you have to look at other areas that comprise a much larger piece of the budget than public health does. There are lots of members of Congress who have said, we need to look beyond just these non-defense discretionary programs and have a balanced approach -- one you get into those details, however, there are more disagreements."

In mid-September the IDSA sent a letter to Congressional leaders, urging them to enact legislation to prevent sequestration. In the letter, IDSA past-president  Thomas G. Slama, MD, FIDSA, and Judith A. Aberg, MD, FIDSA, chair of the HIVMA, write, "If sequestration is allowed to proceed, it will devastate our nations public health infrastructure and biomedical research enterprise, which have already borne a disproportionate share of budget cuts in recent years. Our leaders understand the need to get the nations fiscal health in order. We also know that investments in infectious diseases and HIV research and public health efforts, development of new drugs, vaccines and diagnostics, and the provision of high quality healthcare can dramatically reduce healthcarecosts in addition to saving countless lives and improving the quality of life for millions of Americans and people worldwide. Investments today pay significant dividends by preventing new infections, avoiding costly treatment interventions such as unnecessary hospitalizations and readmissions, and preventing permanent disabilities and deaths... Instead of allowing sequestration to blindly reduce funding for all programs, with no ability for Congress to weigh critical priorities, we urge you to adopt a balanced approach to deficit reduction that ensures that our nations public health and healthcare system are protected and strengthened. As you undertake the serious and challenging task of evaluating the nations funding and revenue priorities, we urge you to protect investments in public health, biomedical research and health services for all populations, especially those most vulnerable."

Jezek says that while the IDSA has received no official response to its letter, "many Congressional staff members have said it is very helpful when organizations like ours that have expertise in these issues weigh in and point out what kind of devastating things will happen if sequestration would take place." Jezek adds, "We're always trying to raise awareness and hopefully alarm people about the terrible things that will happen if they don't do something. We continue to advocate on the Hill on these issues to get that message out. We have an action alert on our website so our members can contact their Congress members directly to explain how their work is affected."