Public Health Funding and the Role of Congress

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: state health officers climb Capitol Hill to stump for legislative support of their public health priorities.

MICHAEL FRASER:
I like to remind people, this is the richest country in the world. I don't know why we're having these kinds of conversations about cuts right now. It really should be a conversation about priorities and where we're investing that have the most impact.

CAROLYN MULLEN:
If Congress does not raise the caps or address it through a bipartisan budget agreement, these cuts will go forward, which would have a devastating impact on all of the non-defense discretionary programs but also our members and the work that they do every day.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, the focus is on Congress and a recent visit to D.C. by state health officials from across the nation to push elected House and Senate members for support on issues like raising the caps on non-defense discretionary spending, supporting the 22 by 22 campaign to increase the CDC budget 22% by FY 22, and prioritizing funding for preparedness programs and the Prevent Block Grant.

Although ASTHO's Capitol Hill Day is over and its members have gone home, the work here in Washington carries on, encouraged by CEO Michael Fraser and the chief of government affairs and public relations, Carolyn Mullen. They're together for our conversation about the Hill Day strategy and the public health policy agenda for 2019.

FRASER:
We are just coming off our Washington Week, which was a great week. And, you know, a lot of people are like, "Why do you do this meeting in March? You know, the state general assemblies are in session, territorial legislatures are in session, and it's really hard for state health officials to get away from their own politics, what's going on in their state." But spring is a key time here in Washington—not sure if everybody knows that—and I'm going to ask Carolyn to talk a little bit about why.

MULLEN:
The real critical period to influence the annual preparations process is from January to March, and it kicks off usually with the release of the president's budget proposal. The release of that proposal typically happens during the first week in February—however, this year it was delayed due to the partial government shutdown.

Once the president's budget is released, oftentimes many advocacy organizations go up to Capitol Hill and educate and advocate with members of Congress, urging them to increase federal funding for their top priority areas. And usually the window for that influence closes around the end of March—this year, it will close on March 28th when the appropriations deadlines are for the House, and April 15th in the Senate when the appropriations deadline is.

FRASER:
Yeah, so we invited members to Washington a couple of weeks ago for that, Hill Day, and the goal was really to tell the story of state and territorial public health, to educate and inform members of Congress about what state issues are, what state public health issues are, what the territorial issues are. And, you know, along with every other trade group and professional association in the world, it seems like, you know, we're making our case for increased support and at least sustained support for our member agencies.

JOHNSON:
Now, we want to get in to some of those issues. But before we dive into them in more detail for people listening, you brought some backup this year, I think, right? Didn't you have another association with you? Is that a new thing?

MULLEN:
For the first time ever, we partnered with the National Association of County and City Health Officials, or NACCHO, here in Washington. And it really—the goal of that was so that we had one voice really urging Congress to increase funding for public health.

So, governmental public health is a partnership between the federal, state, and local governments; and so, including them as part of our Hill Day really helped amplify that message that we need sustained increased federal funding to support all functions of the public health system.

FRASER:
Yeah, governmental public health is a team sport. It happens in state capitals and happens in big cities and rural counties. And we were really looking forward to this partnership with NACCHO—the National Association of County and City Health Officials—and the Big Cities Health Coalition to tell this story of public health from their perspective.

I wouldn't say they were backup, they were definitely partners on the Hill. And one of the things that was great about that was, you know, there's only 59 states and territories and not all of the state health officials are able to attend our Hill Week. So having, you know, representatives from the National Association of County and City Health Officials and Big Cities was super important to not just beefing up our numbers, but telling their story in terms of what public health looks like in a state.

And sometimes the state health department is the local health department, so there are states where the state health agency runs local units; and in some states they're completely autonomous, they do their public health work as autonomous counties or cities. And it was just a really good chance for us to go together because one of the messaging problems we have in public health is everybody going for their little piece. And what this event was really all about was a big ask for all of us, not our little piece or our little category.

JOHNSON:
How many people did you have altogether?

MULLEN:
So, we had about 18 state and territorial health officials. And combined with NACCHO, we definitely had over 100 public health officials up on Capitol Hill.

JOHNSON:
So you were able to cover a lot of ground.

FRASER:
We did.

MULLEN:
We did. It was very exciting.

FRASER:
We would tell people to wear comfortable shoes.

JOHNSON:
There's a lot of walking in Washington, there is no doubt about that.

What would you say are, or were, some of the highlights in terms of meetings that were held or feedback that you received? What's the post-mortem on this?

MULLEN:
The post-mortem is generally the mood on Capitol Hill was receptive to our request for increased federal funding for public health. And they really loved hearing more about what was happening at the state and local level as it relates to public health.

I was able to attend a meeting with some of our health officials, and the member of Congress's staff went right into the weeds about a water issue they were having in the state; and they wanted to know more about what the role of public health was and the environmental health agency. And it really was a great example of a relationship being built.

Which is what we really want the output to be from these meetings, is that it's the beginning of a conversation, but we really want members of Congress to understand what this federal funding goes to in the state, the role of the state and territorial and local public health department, and how the federal government can be partners in really promoting and protecting the health of the population.

FRASER:
One of the key set of meetings we had was with leaders of the appropriations committees. And those are the influencers, those are some folks that are really important to us that are making decisions about funding for public health agencies. So, we were able to do a few meetings either with staff or with members of those appropriators' offices to make that case. And that's super important—you know, I think that was really good, and big highlight.

Another highlight of the week was seeing our current president, Nicole Alexander-Scott, with Senator Whitehouse from Rhode Island—they are both from Rhode Island—and it was clear they knew each other and he understood what the priorities were for the state, and there had been a lot of legwork done prior and a relationship built. And so, he attended our breakfast on our Hill Day in the Senate and said a few remarks, which I think were really helpful to setting the tone for the day. It was a really great event.

JOHNSON:
You've mentioned the priorities a few times, touched on that. In list form, what were they?

MULLEN:
So, we are gravely concerned about the return of sequestration this year, and sequestration was enacted in the Budget Control Act many years ago. And what sequestration means is a $55 billion cut to non-defense discretionary programs, which translates into about a 10% cut. If Congress does not raise the caps or address it through a bipartisan budget agreement, these cuts will go forward, which would have a devastating impact on all of non-defense discretionary programs but also our members and the work that they do every day.

So, our top ask was for Congress to develop the bipartisan budget deal to raise the caps to address sequestration. Then, once you have that budget deal in place, you're able to ask for predictable, sustained, increased federal funding. And that's our 22 by 22 campaign, which is urging Congress to increase federal funding for the Centers for Disease Control and Prevention, 22% by FY 22.

Why 22%? 22% translates to about a $500 million increase for the next three years, or $1.5 billion total. Why FY 22? That's when the Budget Control Act caps expire, and it really will enable that sustained and predictable growth for state and territorial health departments to do their important work.

So, we're not asking for a doubling of CDC, for example. We're asking for an infusion of the funds necessary to ensure that we aren't just oscillating from crisis to crisis, and we're really building that core capacity and investing in the infrastructure at the state and territorial and local level for our members to do their important work—whether it's addressing the recent measles outbreak, or the opioid epidemic, or HIV/AIDS, or preventing chronic disease. It's really vitally important that we continue to invest and promote public health.

FRASER:
There's a lot of talk about money in governmental public health. We don't actually look for a lot of new legislation—our advocacy agenda is pretty lean and mean at ASTHO—and so we do spend a lot of time on appropriations. One of the big reasons for that is because state health departments get about 40 or 50% of their total budget from the federal agencies. So, anything that happens in Washington impacts public health at the state and local level.

And while we do spend a lot of time talking about money and increases—or at least trying to avoid cuts—it's the priority. It's the priority for state health officials because, when you think about what a health department really is, it's a group of talented, dedicated people, and they don't make a lot of stuff. You know, they don't buy a lot of equipment—you know, if you're in the laboratory, they might. But those funding changes have a dramatic effect on the ability of an agency to respond.

And I think, as Carolyn mentioned, measles is a good example of that; and not having a sustainable source of funding to respond to measles outbreaks, they had to pull agency staff from all other functional areas in the health department in Washington state. And you got to ask, "So, you know, who are those people, and who did their jobs when they were working on the measles response?" So, that's just one example of how states use this funding and why it's so important to talk about appropriations in public health and understand that process. It gets pretty technical pretty quickly.

And ironically, the president's budget came out Monday and we had our Hill Day on Wednesday, and people were really scared from looking at the president's budget and the proposed cuts to health and human services agencies. You know, those of us who lived through presidents' budgets know that's not law, and actually we have some even bigger threats to public health that are real like the sequester Carolyn was talking about and caps to the FY 20 budget.

JOHNSON:
Well, the old saying, you know: the president proposes, Congress disposes. What is the sense that you get from the Hill about what Congress wants to spend on public health this time?

MULLEN:
They will not enact the president's budget proposed cuts of 12% for HHS, and that's pretty much a bipartisan agreement.

We saw last year in the House FY 19 Labor, Health and Human Services, and Education Appropriation Bill, and that's the bill that funds NIH and CDC and HRSA and other agencies. We saw for the first time a really significant investment for CDC—about $450 million increase in FY 19.

Granted, when it went to conference and negotiations happened, we did not see that high level of investment. But that was a Republican-controlled committee a year ago, and they were really expressing the need to invest in CDC. And also, they provided some resources for an infectious disease rapid response fund for the first time ever. I think at the end of the day, it ended up getting $50 million.

But there's an acknowledgment on the Hill that now's a time to invest in public health. I'm really excited to be part of this advocacy journey right now because I think Congress is seeing when you don't invest and when we have these crises—whether it's Zika or hurricanes or measles outbreak or a water crisis, for example—that you notice that there's kind of this crumbling infrastructure, and we really do need to be investing in these core programs so that when these crises strike, we are better prepared than we have been before.

We don't have to take people off of their day-to-day jobs to respond, that we have the resources available to prevent these outbreaks from happening in the first place. You had Dr. Weissman, who's our state health official from Washington state, said it's costing the state about $1.5 million to address the measles outbreak. It costs $20 to get the vaccination. Imagine how many dollars we could save if we prevented this outbreak from happening in the first place.

FRASER:
I would totally agree. I think that the message we have is about building the public health system. And one of the things that is sort of a silver lining from the opioid epidemic has really been the role of public health and prevention in that. And to make the case that, you know, we're not going to treat our way out of this epidemic, but instead we've got to start looking at prevention and what are some of the ways to prevent addiction in the first place. And that's the work of public health.

So, you know, unfortunately we've had lots of great examples of, you know, why we need public health: ranging from measles to the opioid crisis, to some of the concerns about environmental health and drinking water. But I think those are ways to make the work of public health real, and public health is usually invisible. Not a lot of people wake up every day and say, "Oh, that's public health," you know, so. And that's true for members of Congress. There is one MPH on Congress, but there are lots of physicians and nurses.

And part of what we have to do is educate folks about what public health is and what state public health is. And it's not healthcare delivery, it's a partner with healthcare delivery. We spend a lot of on healthcare delivery. A lot of the budget pressures we're facing are due to mandatory programs that provide healthcare and, you know, it gets technical really quickly. But I think one of the things we try to share is if we even made, you know, a fraction of the investment we make in healthcare delivery in public health and raise that, we could do a lot to improve health and also save money.

JOHNSON:
Let's talk a little bit more about 22 by 22—you touched on that when you were giving us an overview. Is that a new campaign?

MULLEN:
It is a new campaign. We launched it last year—we did a soft launch last year—and right now we have over 80 national organizations who have endorsed it.

We really took a page out of the National Institutes of Health's advocacy playbook. So, what the National Institutes of Health advocacy community does really, really well is they talk about the top line funding level for NIH every year and they do it so well where Congressional staff actually can repeat the talking points back to you. And if they're testifying up on Capitol Hill, they all speak with one voice and they lead with the top line number for NIH, as opposed to their little piece of the pie.

And so, we really wanted to mimic what the NIH community is doing and talk about all of public health and the vital role of all the programs at CDC. At ASTHO, our members oversee many—almost all—of the programs that CDC funds. So therefore, why would we talk about this line item over that line item, or this program over that program? We really want to talk about the whole.

So, that's the goal with this campaign, and then it's really up to Congress to decide how they want to allocate those $500 million. Hey, you're Joe Smith from Nebraska and you are dealing with the opioid crisis. Okay, allocate some funds there. You're Jane Doe from South Carolina and you're dealing with measles outbreak, allocate funding to the 317 immunization programs. So, we really want to keep that high level and to allow members of Congress to really decide based on their priorities for public health to allocate those resources.

But again, we really want to sustain predictable funding for our members and then also the 80 national organizations support that approach as well.

FRASER:
The traditional approach in public health has been very categorical and a lot of advocates seek support for a particular issue. So, I like to talk about the body parts and diseases advocates. And those are super important, I don't want to minimize that at all; but you know, there's never been a collective ask that has been branded and clear, I think, in the way that the 22 by 22 campaign is trying to achieve.

And again, you know, as Carolyn said, the thrust of it is to have this umbrella, this big tent, and include those programs, you know, in conversations in the future when we do get the increase. Because, you know, success for the public health system is not a group going in and getting $10 million for their program, or $1 million for their program, or, you know, some three centers of excellence somewhere. That's not building the kind of investment that we need.

And so, we're really thinking that 22 by 22 is a way to talk about increases to the public health system in a way that legislatures will hopefully remember. So, you know, that's part of it. And it's realistic—it's not totally outlandish to think we could do this by 2022.

And I think the other thing I would say is we know there's more to the public health system than what CDC does. And we certainly care about the other federal agencies and partners at HRSA, and FDA, and a lot of the other agencies with which we work. We're really concerned given the threats to CDC funding and its really close affiliation with the prevention fund and all of those factors that really contribute to CDC being a little more vulnerable right now. But we would certainly—and are certainly—thinking about, you know, writ large, what do we need for public health and getting those other agencies engaged?

JOHNSON:
How did CDC fare in the administration's budget? I think it was cut, right?

MULLEN:
It was cut.

JOHNSON:
By a lot?

MULLEN:
Yes, by a lot.

JOHNSON:
So, you're looking to restore? Maintain the current level and then build on that?

MULLEN:
Exactly.

FRASER:
So, you know, there's this classic "robbing Peter to pay Paul" dynamic that goes on in the budget. And so, one of the things in the president's budget is this America's Health Block Grant—sounds great, states love block grants, that gives them flexibility, it's $500 million. Well, to fund that, it comes at a cost of all of these other cuts to the public health system, especially at CDC. So that's, you know, that's not a good deal.

And so one of the things that, you know, we're constantly trying to play defense on these little cuts that take from one place to plus up somewhere else. And one of the great things about the Bipartisan Budget Act a couple of years ago was that it raised the caps so that we didn't have to have this conversation about where are we going to cut to get an increase?

We are so supportive of the president's initiative to eliminate the HIV epidemic, or end the HIV epidemic. That's fantastic. We absolutely—you know, we've been trying to do that, and there states that are getting to zero and all of that work. But we can't fund that at the expense of all of this other work that needs to be done. That's not how you build a system.

And so, it's a constant theme in public health advocacy that the issue that's—I'm not going to say the issue du juror, but whatever the most salient issue is, like let's say opioids, or let's say measles, or let's say Ebola, you know, let's pay attention to what's going on around the world—comes at the expense of existing programs, and that's just no way to build a system or to be effective.

JOHNSON:
Did you discuss, when you were on the Hill, ways to fund these increases? Did you propose any ideas there? What's the answer on that question?

FRASER:
You know, a lot of people ask that question, and I learned early in my career that that's not my job to figure it out. I think that, really, that is Congress' job. And we have a lot of priorities in this country. We think public health is the primary, and it's our hope that we elect people that agree with that and are willing to make those kinds of decisions.

But to throw in another program under the bus and say, "We don't need that program," they're going to come in tomorrow and say, "We don't need the public health." And then you end up in this eye for an eye, tit for tat lobbying. And I've seen people fall into that trap, and it's created a lot of animosity—it's burnt bridges, it's ended relationships—and it's not an effective way for us to operate.

Obviously, all of these programs come at a cost. I like to remind people this is the richest country in the world. I don't know why we're having these kinds of conversations about cuts right now. It's really should be a conversation about priorities and where we're investing to have the most impact.

JOHNSON:
The members have all gone home, you're still here in Washington. What's left to do? What's next?

MULLEN:
The great piece about working at the Association of State and Territorial Health Officials is they have the government relations team. So, even though our members are not here in Washington, D.C., the team's work continues. So, earlier this week, I was with members of Congress—new freshmen members—educating them about sequester and the caps and the role of public health, for example.

But when our members go home, we really encourage them to continue to build the relationship. So, when they get home, they were supposed to write a thank you note, thanking the member of Congress and their staff for their time. And then, they're supposed to follow up with key information on what's happening in their state. I urged our members to at least have four points of contact with members of Congress and their staff throughout the year in order to build that relationship.

We'll also be encouraging state and territorial health officials to meet with their members of Congress during the upcoming August recess and invite members of Congress to tour their health department and state labs so they can really learn what's happening on the ground in their state. So, it's a two-pronged approach.</p<

Our members have roles and responsibilities when they go back home, and I still have my day to day job here in Washington, D.C. to continue to advocate and educate on their behalf, and also let them know when things are coming down the pipeline that could impact their bottom line.

FRASER:
It's important for our state health officials and our territorial health officials—and some of these territorial health officials fly days to get to Washington—it's important for them to come. There's only so much advocacy that we can do, and there's only so much legitimacy we have as advocates who are working professionally for ASTHO. But when a constituent and a leader in public health comes to Washington and can sit down with staff or with the member of Congress and say, "Here's what's going on in our home," that has huge impact, well beyond any professional lobbyist. And usually these folks have relationships, so that's really positive.

I think that the work that we do in between our spring fly-ins obviously is important, and we try to stay in touch with our members. We have a government relations committee that advises the association when things pop up. We provide a lot of education to members about what's going on—we often send legislative alerts to keep them informed—and to continue that drum beat back in the District. And really, again, as Carolyn mentioned, make time to visit, to really try to be strategic about getting members of Congress to see the work of public health.

And that's not just members of Congress, that's state folks, too. I was having a conversation today with the new health official in Georgia, and she was talking about bringing the governor to CDC to really show what CDC does to the governor who's home to the CDC in Atlanta. And these are the kinds of things that we also try to do with Congress.

JOHNSON:
So, if we're back in the states and we've done this work and we're hopefully doing our homework, what are we expecting next on the timetable? It's tough predicting Congress—but today, what do we think?

MULLEN:
Right. We do have the appropriations deadlines, and the appropriations deadlines that the committee set is when the wishlists are due to the committees. And that's when each individual member of Congress writes a letter to the appropriation committees and says, "These are my top five things that I would like to see in the appropriation bill." So, for the House it's due at the end of this month; and Senate, it's due in April.

After those wishlists are compiled by the appropriations committees, we are going to see a markup in the House of the labor, health and human services, and education appropriation bill at the end of April. The House wants to move very quickly to get the FY 20 bill marked up.

The top line number, or the overall allocation for that committee, is still TBD. Since we don't have a bipartisan budget deal, they will most likely be marking up to not realistic numbers. So, we should expect higher numbers on the House markup at the end of this month.

Then, the Senate is going to move on to their version of the bill sometime at the end of May or early June. And then, we'll see what that bill has. I think the overall amount of funding that they are going to be marking up to is going to be less than the House. So, you're going to have these disparities between the two bills. One bill is going to be a lot more money, the other bill isn't going to be as much money as we would like to see, probably. And then, they're going to have to conference it and resolve those differences.

But none of that can happen unless they address the sequester caps and develop a budget deal to get to those top line numbers. So, it will be a pretty busy spring and summer where we see the results of our work in those appropriation bills. And then, we are gonna have to wait and see to find out what happened in the fall.

We are hearing that the White House would like to wait until the fall to develop a deal potentially, but I'm unsure whether President Trump wants to have a bipartisan budget deal to raise the caps for non-defense discretionary spending, and how does the wall factor into that. And will we have another government shut down in October? I think the likelihood of that is relatively high at this point.

FRASER:
Yeah. Remember, the federal budget starts in October, October 1st. That's why these appropriations bills—well, many, many years ago—come out over, you know, early summer, into the summer. And that's why we see so many shutdowns because they can't resolve some of these differences. I think Carolyn did a good job of explaining the process.

I think we could anticipate shutdowns, continuing resolutions. One of the things the last year that was great, at least for Labor-H, was they actually passed an appropriations bill. And so, when that last shutdown happened, it didn't impact public health than the way it could have. Certainly impacted the FDA, it impacted the Indian Health Service, it impacted the EPA, it impacted CDC's ATSDR; but some of the core public health programs knew what their funding levels were going to be for the year and didn't have to worry too much about it.

I'm not sure that's going to happen again, I'd be surprised. But this town is—always something new happening, right?

JOHNSON:
Never a dull moment.

FRASER:
Never a dull moment, and it's a long, hot summer.

JOHNSON:
It is. So, let's wrap this up.

When you look at the fly-in that you just hosted, compared to others that you've done in the past, how does it rank? How did you do? What grade would you give yourself and your members for this effort?

MULLEN:
I give my members an A.

FRASER:
I give our members an A, I give our team an A. Carolyn's going to give herself a C because she's always so critical of herself.

MULLEN:
I give ourselves an A because people show up, and showing up in Washington, D.C. and taking time out of their extremely busy schedules is immensely important and very valuable. So, we had 18 SHOs—state health officials—who attended. Hopefully next year, there'll be a little bit more, but they're in the middle of a lot of legislative sessions at the state level. So, it meant that they had to take time off from that and come and spend time with their members of Congress and staff.

So, I thought it was a great experience. I thought having NACCHO as a partner for our Hill Day was wonderful, to help amplify that message up on Capitol Hill. And I just hope, you know, when we see these bills in the next couple weeks that we will see those 22 by 22 increases for public health. I mean, that's really where the rubber meets the road and where you can see your hard work hopefully go into action.

FRASER:
I think it was an A. I think that having NACCHO with us, the NACCHO members with us, the Big City health officials with us, helped a lot. Some folks may focus on the number of health officials that show up, like 18. Well, we had about 22 new ones, so it's hard to expect them to get out of state the first two months of their jobs in the middle of their budget seasons, too.

I think real success is going to be when we hear members of Congress talking about 22 by 22, when we hear members of Congress really talking about the need for a strong public health system. And, you know, we hear that in bits and pieces now, but more echoes of that would be awesome. And I'm sure we are going to get there.

I mean, I agree with Carolyn, who said earlier that there was a different mood, maybe more appreciation for what public health does and an understanding of the need to prioritize that in a new and different way, given all the threats that we have and the costs that we're incurring and just the real need to start making smart investments in prevention.

JOHNSON:
The ASTHO website offers members the tools needed to share key messages and policy positions with elected officials in the states. There's a toolkit for those planning to meet with their members of Congress. The site also features a complete set of advocacy documents covering appropriations, state profiles, and the 2019 legislative overview series fact sheets.

As always, look for the links to these documents and more in the show notes for this episode.

Thanks for listening to Public Health Review.

If you liked the show, please share it with your colleagues. And if you have comments or questions, we'd like to hear from you. Email us at pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.