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Public Health 101: The leading Challenges
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Testimony

Submitted Testimony
House Subcommittee on Labor, Health and Human Services and Education Appropriations

May 9, 2003

"Health is a primary public good because many aspects of human potential such as employment, social relationships, and political participation are contingent upon it. In view of the value of health to employers, business, communities, and society in general, creating the conditions for people to be healthy should be a shared social goal." Institute of Medicine, 2003. The Future of the Public's Health in the 21st Century (Pre-publication copy.) Washington, D.C.: National Academy Press, p. 2.

The Coalition for Health Funding is pleased to provide the Subcommittee with testimony recommending FY '04 funding levels for the agencies and programs of the U.S. Public Health Service. Since 1970, the Coalition's member organizations, representing 40 million health care professionals, researchers, lay volunteers, patients and families, have been advocating for sufficient resources for PHS agencies and programs to meet the changing health challenges confronting the American people. The Coalition for Health Funding is the nation's oldest, most broadly based alliance focused on the breadth of discretionary health spending. One of the important principles that unites the Coalition's members is that the health needs of the nation's population must be addressed by strong, sustained support for a continuum of activities that includes biomedical, behavioral and health services research; disease prevention and health promotion; health care services for vulnerable and medically underserved populations; ensuring a safe and effective food and drug supply; and education of a health professions workforce in adequate numbers to address the breadth of need.

Since the terrorist attacks of September 11, 2001, and the subsequent anthrax attacks, the public is acutely aware of the role of public health in protecting them from the consequences of terrorism involving biological, chemical, or nuclear agents. The events also have dramatically demonstrated the extent to which the nation's public health infrastructure has been allowed to deteriorate. The Coalition for Health Funding applauds the extraordinary Congressional response to this serious deficit and supports the President's FY '04 request for continued public health infrastructure enhancement.

But while government agencies at the local, state and federal levels have a leading role in preparing for and responding to the terrorist challenge, all aspects of our health and public health system are critical to the success of this effort. It is relatively easy to understand the importance of strengthening the ability of local, state and federal public health agencies' ability to detect and respond rapidly to a deliberately released infectious agent, such as anthrax or smallpox. The importance of addressing racial and ethnic health disparities and access to essential medical care services in the context of the threat of bioterrorism may seem less clear - but populations at higher risk for both chronic diseases and naturally occurring infectious diseases and with less access to health care services are both more vulnerable to deliberately introduced diseases and less visible to the health care system when hours count. Similarly, it may be easy to understand the need to train more public health professionals, such as epidemiologists and public health lab technicians, to prepare and respond to terrorism. But who will take care of those who fall ill, or who need emergency vaccinations, or preventive medicines when we are facing serious shortages in the number of nurses, pharmacists, and allied health professionals? These and many other activities supported by the PHS agencies and programs, such as vaccine research conducted at the National Institutes of Health, medical errors research conducted at the Agency for Healthcare Research and Quality, and food and drug safety review conducted by the Food and Drug Administration, are clearly related to bioterrorism preparedness and response and need strong support. At the same time, even those activities that cannot be linked to bioterrorism, such as preventing birth defects, heart disease, or HIV/AIDS, are essential in our preparedness efforts because a healthy America is a strong America.

The whole continuum of public health activity must be strongly supported to achieve both optimal terrorism preparedness and optimal health outcomes for the American people.

Each year, the Coalition for Health Funding works with other health alliances to determine an appropriate level of federal support for health discretionary programs. For FY '04, the Coalition is recommending $54.5 billion be provided for the major programs and agencies of the U.S. Public Health Service. The Coalition's recommendation also includes funding for the Indian Health Service and the Food and Drug Administration, which are not within the jurisdiction of this Subcommittee, but are important federal public health agencies. The Coalition appreciates that these funding levels, 14.4 percent over FY '03 and the President's request, may appear excessive, but they reflect both the professional judgment within the various agencies as well as our own members' assessment of community and national needs. The Coalition presents these recommendations to the Subcommittee in the hope that it will view them as important targets in our efforts to achieve our mutual goal of improving the health and quality of life for all Americans. On the other hand, the Coalition is very concerned that the President's overall FY '04 request for public health programs provides virtually no increase and does not even provide enough funding to maintain current services. Within this constraint, selecting certain programs for increases results, necessarily, in cuts, many severe, for other public health programs.

The following is a partial list of the Coalition's findings and recommendations; the attached table provides the Coalition's recommendations for all the public health agencies:

National Institutes of Health (NIH)

The Coalition supports $30 billion in FY '04 for the National Institutes of Health, a 10 percent increase over the FY '03 funding level, to provide sufficient resources to sustain the momentum of the recently completed campaign to double the nation's investment in the promising research supported and conducted by the NIH. The President's request to provide $27.7 billion, or a 2.1 percent increase over FY '03, is inadequate to fully reap the research opportunities that the doubling campaign have made available, particularly as a result of the scientific achievement of sequencing the human genome and the large economic benefits that accrue as we make progress against diseases. Recent NIH investments have helped create new diagnostic methods, new treatments, new vaccines, and new cures. Just a few of these examples include Hepatitis B, Haemophilus influenzae Type B, pneumococcus and pertusis vaccines with the potential to save millions; the development and FDA approval of Gleevac for use in treating chronic myelogenous leukemia; and newly developed medications for schizophrenia that have reduced hospitalizations by 30 percent and saved $1.7 billion in annual hospital costs.

The Coalition also appreciates that medical research is a vision not a precise blueprint. It must be flexible enough to respond to society's changing health care needs and dynamic enough to open the way to ever more promising frontiers of fundamental research. Scientific discoveries are the result of a series of incremental steps that pave the way for future breakthroughs. This process needs sustained support. With it, and support for other public health partners, we will be ready to meet the challenges of the future.

Centers for Disease Control and Prevention (CDC)

The Coalition for Health Funding recommends an overall funding level of $7.9 billion for CDC in FY '04. This amount is $2.3 billion more than the FY '03 funding level and the President's request for FY '04. The Coalition believes this is the amount needed to enable CDC to carry out its vital mission of disease prevention and health promotion. This is more evident than ever with the advent of SARS and its worldwide threat to human health.

The Coalition is extremely pleased that Congress provided $1.5 billion in FY '03 to the CDC to continue the process of re-building the nation's seriously eroded public health infrastructure in order to prepare for bioterrorism and other terrorism threats. The Coalition also appreciates the provisions within the just passed FY '03 supplemental appropriations bill (H.R. 1559) for additional resources for CDC to combat SARS and to reimburse state and local health departments for costs incurred with the administration of the smallpox vaccine. In addition, the Coalition supports the President's FY '04 request for $1.1 billion in funding for bioterrorism preparedness, the third installment of significant resources to strengthen the nation's public health infrastructure. The Coalition recognizes that this level of funding will need to continue for the foreseeable future to truly re-build our public health system at the local, state and federal level.

The Coalition is also very pleased with the President's budget request for increased funding for chronic diseases, with an emphasis on obesity, asthma and diabetes - all conditions which have reached epidemic proportions in the general U.S. population. This is an important investment across the U.S. Public Health Service with CDC as the lead agency. However, the Coalition feels that all aspects of chronic disease, such as heart disease and stroke, cancer, arthritis, tobacco related pulmonary diseases, and oral health, need on-going support and in many instances increased support. Chronic diseases constitute the nation's most costly health problems accounting for over 70 percent of health care costs.

There are many other aspects of the President's FY '04 budget request for the CDC that are troubling. A number of programs are cut in funding when compared with FY '03 funding levels such as environmental health (-18 percent) birth defects, disability and health (-11 percent), occupational safety and health (-10 %) and, before the supplemental appropriation for SARS, infectious disease control (-4.7 percent). Many other programs are flat-funded such as domestic HIV/AIDS, STDs and TB prevention, the preventive health block grant and injury prevention and control. We cannot afford, as a nation, to diminish our investment in programs that do so much to achieve improved health outcomes, many by translating knowledge gained through our investment in the NIH. By cutting, or flat-funding, CDC programs we harm our overall progress toward building a healthy, strong America.

Health Resources and Services Administration (HRSA)

The Coalition for Health Funding recommends an overall funding level of $7.5 billion for HRSA in FY '04. This amount is $480 million more than the FY '03 funding level, or 6.8 percent, and is the amount that the Coalition believes is needed to provide adequate resources for the important programs that HRSA administers that address access to needed medical and health care services for medically underserved populations. The Coalition's recommendation is fully $1.2 billion more than the President's request of $6.3 billion for HRSA, or 19 percent higher.

The Coalition is pleased that the President has requested a significant 7.5 percent increase for community health centers for a total of $1.627 billion, although this, once again, falls short of the amount needed to achieve the President's expressed goal of doubling the number of health centers over five years. The Coalition is also pleased to see funding maintained from FY '03 levels for hospital planning and infrastructure preparedness for terrorism threats, as well as continued support for health professions school curriculum development for bioterrorism training. However, the Coalition is puzzled about why the President's budget zeros out funding for the Trauma-EMS program when, to date, the vast majority of terrorist attacks have involved conventional weapons and terrorist victims, as well as those seriously injured in everyday occurrences, absolutely depend on the readiness of states' trauma care systems. Finally, the Coalition is pleased to see an increase over FY '03 for the Title V Maternal and Child Health Block Grant of $16.3 million. However at a 2.2 percent increase over FY '03, this is not enough for this safety net program to meet the increasing needs of the population it serves, needs that have been exacerbated by deep state budget cuts and an upsurge in the number of families needing TANF assistance.

There are many other areas in the HRSA budget that the President proposes to cut deeply that the Coalition opposes. Chief among these is the elimination of the Title VII Health Professions Education programs. These programs are beginning to document formally what its supporters have long known: that it has a solid track record in recruiting and training the kind of health professionals that practice in, and stay in, medically underserved areas; and it has a solid track record in training needed health professionals in short supply. These now include pharmacists, allied health professionals, dentists, a range of public health practitioners, psychologists, and physician assistants. Despite considerable documentation of the nursing shortage crisis, HRSA's nurse training programs are cut as well -- by 13.6 percent over FY '03 funding levels, or $15.5 million.

The Coalition also opposes a proposed 32 percent cut, or $93 million, to the Children's Hospitals Graduate Medical Education program that trains physicians providing direct care for children in free-standing children's hospitals. Similarly, the Coalition opposes the proposed elimination ($120 million) of the Community Access Program designed to help communities address the still massive numbers, over 40 million, of uninsured Americans. Overall, the President proposes to cut existing HRSA programs by $730 million, or 10 percent - again, at a time when the combination of severe cuts to many state health budgets and the economic downturn is increasing the number of individuals and families turning to federally funded programs for assistance and care.

Also disturbing is the proposed level funding for many other programs. This includes the Ryan White CARE Act programs at time when the U.S. is experiencing an increase in the number of new HIV/AIDS cases. The President's request for Ryan White programs, when compared to FY '03 levels, provides level funding for all titles except for the AIDS Drug Assistance Program which receives a $20 million increase. Family Planning services, which support 4,600 clinics across the U.S. that provide comprehensive services including screening for cancer, HIV, and other diseases as well as contraception and teen pregnancy prevention, are another critical safety net service that needs increased resources.

Substance Abuse and Mental Health Services Administration

The Coalition for Health Funding recommends an overall funding level of $3.8 billion for SAMHSA in FY '04. This amount is $632 million more than the FY '03 funding level, or 19 percent, and is the amount that the Coalition believes is needed to provide adequate resources for the agency charged with leading national systems addressing mental illness and substance abuse. The Coalition's recommendation is $407 million higher than the President's request of $3.393 billion.

The Coalition appreciates the President's request for an additional $208 million for substance abuse treatment, as only 20 percent of the 13-16 million people needing treatment services are currently receiving care. However, this increased funding is structured as a voucher program that entitles substance abusers to treatment in a variety of settings, including faith-based organizations. The Coalition cautions that substance abusers need the services of credentialed professionals and hopes the new program will encourage access to recognized treatment and also be carefully evaluated. The Coalition notes that the increase in substance abuse treatment, once again, is funded at the expense of substance abuse prevention. The President's request for prevention is $50 million, or 25 percent, below FY '03 funding levels. Although treatment saves taxpayers $7 for every $1 invested, prevention can reduce the need for any treatment for many people. Both efforts need increased and sustained resources.

Mental health is cut $28 million, or 3.2 percent below the total FY '03 funding level of $862 million in the President's budget request. This is most unfortunate when over 50 million adults in the U.S. are affected by mental illness in any given year and more than 5 million adults and children are diagnosed each year with a severe mental illness, such as schizophrenia. People can and do recover, but recovery depends on getting services when and where they are needed - preferably early in the course of the illness and close to home. SAMHSA is working with its state, local and private sector partners, is instituting state-of-the-art systems of care for those who suffer from mental illness.

Agency for Healthcare Research and Quality

The Coalition for Health Funding recommends an overall funding level of $390 million for AHRQ in FY '04. This amount is $81 million more than the FY '03 funding level, and is fully $111 million above the President's request of $279 million.

The Coalition is, once again, very disappointed in the President's request for a significant cut for this agency totaling $30 million, or nearly 10 percent. AHRQ is charged with providing critical information on healthcare quality, developing methods to reduce medical errors, assessing ways to improve access to healthcare services and utilize healthcare resources more efficiently, translating research into practice, and assisting in improving emergency responsiveness. A cut of this magnitude will dramatically curtail AHRQ's ability to carry out its mission. It will, for instance, be unable to fund any new research or training grants and funding for current grants for non-patient safety research will be reduced by 15 percent, reducing our knowledge and understanding of how to provide cost-effective, quality healthcare. As we move, again, into double-digit medical inflation and face the tremendous challenge of an aging baby-boomer population, the research conducted by AHRQ is more relevant and more needed than ever.

The Coalition sincerely appreciates this opportunity to provide its FY '04 funding recommendations to the Subcommittee for the agencies and programs of the U.S. Public Health Service. The Coalition's recommendations for all of the public health agencies are provided in the accompanying table. The Coalition, and its member organizations, look forward to working with the Subcommittee in the weeks ahead to improve the health of all Americans.

Coalition for Health Funding 2004 Recommendations
(In Millions of Dollars)

*Relects Program Level minus user fees and mandatory spending, but does include Bioterrorism
funding from PHSSEF and current law
**Reflects Total Budget Authority
***Reflects Total Program Level
+ Shows comparables: Does not include National Emergency Stockpile now transferred to the
Department of Homeland Security
++ Estimated

©2008 Coalition for Health Funding