WASHINGTON, Aug. 6 (TNSrep) — The Congressional Research Service issued the following report (No. R47207) on Aug. 5, 2022, entitled “Centers for Disease Control and Prevention Funding Overview.”
The report was written by health policy analyst Kavya Sekar and public health emergency management analysts Hassan Z. Sheikh and Taylor R. Wyatt.
Here are excerpts:
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SUMMARY
The Centers for Disease Control and Prevention (CDC) is a federal public health agency that develops and supports community-based and population-wide programs and systems to promote health-related quality of life and to prevent the leading causes of disease, injury, disability, and death, both domestically and globally. In addition, the Agency for Toxic Substances and Disease Registry (ATSDR) is headed by the CDC director and is tasked with identifying potential public health effects from exposure to hazardous substances. This CRS report provides an overview of CDC‘s budget and appropriations with a focus on FY2022 enacted appropriations and the FY2023 President’s budget request. The report also discusses supplemental appropriations for CDC and trends in state and local funding for public health. ATDSR appropriations are included within the overall discussion of CDC funding.
This report divides CDC‘s program level, or annual funding from all sources of budget authority, into two categories, with a focus on the first:
1. a core public health program level that funds most of the agency’s main public health programs. This is made up of discretionary and mandatory appropriations that are mostly provided or allocated through the Departments of Labor, Health and Human Services, and Education, and Related Agencies (LHHS) appropriations act, and
2. other mandatory programs that include several CDC-administered health services, compensation-related, and user fee programs. These include the World Trade Center Health Program and user fees for cruise ship inspection, among others.
CDC‘s enacted FY2022 (P.L. 117-103) core public health program level is $8.482 billion, which represents a $606 million (+7.7%) increase from the FY2021 final core public health program level, and is $1.1 billion (-11.5%) less than the President’s FY2022 budget request. President Biden has proposed an FY2023 core public health program level of $38.76 billion, an increase of $30.277 billion (+356.9%) relative to the FY2022 enacted level. Of the total increase, 92.5% of the amount is from a new proposed mandatory pandemic preparedness appropriation of $28 billion. Excluding the pandemic preparedness funding, the proposed core public health program level is $10.675 billion, which would represent a $2.273 billion (+27.1%) increase over the FY2022 enacted program level.
From FY2011 to FY2021, CDC‘s core public health funding level has remained between approximately $6.5 and $8 billion until the increase provided in FY2022 (not adjusted for inflation). The lowest funding level of $6.28 billion in 2013 included budget sequestration of nonexempt discretionary spending. CDC also frequently receives one-time supplemental appropriations in response to specific incidents–such as infectious disease threats, natural disasters, or screening and health support to refugees. In response to some incidents, such as the ongoing Coronavirus Disease 2019 (COVID-19) pandemic, supplemental appropriations are substantial and are tied to short-term funding increases for overall public health capacity at the federal, state, and local level. (These are not included in core public health funding as they are not intended to fund the regular operating expenses and programs of the agency.)
In the United States, most public health activities are carried out by state and local governments. A large portion of CDC‘s annual budget is awarded as external financial assistance to state and local health departments (typically in the form of grants or cooperative agreements). In addition to CDC funding, funding trends at the state and local level have a significant impact on overall U.S. public health capacity. There is no source of standardized and generally accepted data on public health funding at the federal, state, and local level, which hinders analysis of public health funding trends. However, several sources indicate that public health funding at the state and local level has remained flat or declined over the past decade.
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Contents
Introduction … 1
Understanding CDC Appropriations … 2
Core Public Health Program Level … 4
Other Mandatory Programs … 8
FY2022 and FY2023 Budget and Appropriations … 9
FY2022 … 10 FY2023 … 10
Pandemic Preparedness Proposal … 11
Other Legislative Proposals … 12
Funding Table … 12
Trends in Core Public Health Program Level … 14
CDC Budget in Context … 16
Supplemental Appropriations for Public Health Emergencies and Other Incidents … 16
CDC Infectious Diseases Rapid Response Reserve Fund … 17
State and Local Funding for Public Health … 19
Trends … 19
Other Funding-Related Challenges … 21
Figures
Figure 1. Centers for Disease Control and Prevention Organization Chart … 2
Figure 2. FY2022 Centers for Disease Control and Prevention Program Level by Category and Budget Authority … 4
Figure 3. Example of CDC Appropriation Language … 5
Figure 4. Example of CDC Appropriations Report Language … 6
Figure 5. Example of Prevention and Public Health Fund Allocations … 7
Figure 6. Trends in Core Public Health Program Level … 15
Figure 7. Inflation-adjusted Trends in State Spending on Public Health by Category Per Capita from Alfonso, Leider, and Resnick, et al. (2021) … 20
Tables
Table 1. Centers for Disease Control and Prevention (CDC) and Agency for Toxic Substances and Disease Registry (ATSDR) Appropriations, FY2021-FY2023 Request … 12
Table 2. Appropriations History to the IDRRRF Account … 18
Contacts
Author Information … 23
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Introduction
The Centers for Disease Control and Prevention (CDC), within the Department of Health and Human Services (HHS), is a federal public health agency that develops and supports community-based and population-wide programs and systems to promote health and to prevent the leading causes of disease, injury, disability, and death, both domestically and globally. Its stated mission is to “protect America from health, safety and security threats, both foreign and in the [United States].”/1
In addition to its role supporting ongoing public health activities, the agency has played a major role in the federal response to the Coronavirus Disease 2019 (COVID-19) pandemic and in other disease outbreaks and public health emergencies. The Agency for Toxic Substances and Disease Registry (ATSDR), headed by the CDC director, is tasked with identifying potential public health effects from exposure to hazardous substances.
Two features characterize CDC‘s mission and programs. First, CDC programs tend to focus on prevention of adverse health outcomes, rather than treatment or clinical care after a health issue arises. Second, CDC programs focus on a population and community-wide health interventions, rather than those that serve individuals. CDC also administers some health services and compensation-related programs as discussed later in this report. CDC is organized into a number of centers, institutes and offices (CIOs) as shown in Figure 1. Some of these CIOs focus on specific public health challenges (e.g., injury prevention), while others focus on general public health capabilities (e.g., surveillance and laboratory services)./2
CDC as an agency is not explicitly established in authorizing law, though the agency is frequently referenced in law – especially in provisions in the Public Health Service Act (PHSA). Many CDC programs and activities are not explicitly authorized but are based in general and permanent statutory authorities of the HHS Secretary, mostly in the PHSA./3
Four CDC CIOs/4 and numerous specific CDC programs/5 are explicitly authorized. CDC also has certain regulatory responsibilities./6
Given CDC‘s mix of general and specific authorizations, appropriations play a central role in guiding the agency’s policy priorities.
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1 CDC, “Mission, Role, and Pledge,” https://www.cdc.gov/about/organization/mission.htm.
2 CDC, “Official Mission Statement & Organizational Chart,” https://www.cdc.gov/about/organization/cio-orgcharts/ index.html.
3 For example, PHSA Section 301 (42 U.S.C. Sec.241) authorizes the HHS Secretary to conduct and support health-related research and investigations. PHSA Section 317 (42 U.S.C. Sec.247b) authorizes the Secretary to award grants to states for preventive health programs, and PHSA Section 319 (42 U.S.C. Sec.247d) authorizes the Secretary to respond to public health emergencies.
4 Explicitly authorized CDC components include the National Institute for Occupational Safety and Health (NIOSH), authorized by the Occupational Safety and Health Act of 1970 (29 U.S.C. Sec.Sec.651 et seq.); the National Center on Birth Defects and Developmental Disabilities (NCBDDD) established in PHSA Section 317C (42 U.S.C. Sec.247b-4); the National Center for Health Statistics (NCHS) established in PHSA Section 306 (42 U.S.C. Sec.242k); and the Agency for Toxic Substances and Disease Registry (ATSDR) established by the Comprehensive Environmental Response, Compensation and Liability Act of 1980 (CERCLA, the “Superfund” law; 42 U.S.C. Sec.Sec.9601 et seq.).
5 Among numerous others, PHSA Sections 317A et seq. authorize lead poisoning prevention activities, and PHSA Title XXXIII authorizes the World Trade Center Health Program.
6 See CDC, “CDC Regulations,” https://www.cdc.gov/regulations/index.html.
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A large portion of CDC‘s annual budget is awarded as external financial assistance (typically in the form of grants or cooperative agreements) – especially to state/7 and local health departments./8
CDC also awards funding to a variety of other entities, including international governments and organizations; tribal governments and organizations; academic and research institutions; and nonprofit organizations.
This report reviews the CDC‘s budget and appropriations from FY2020 to FY2022 and its funding history for core public health programs from FY2011 to FY2023. It also discusses selected policy issues related to CDC appropriations, including the roles of emergency supplemental funding and state and local funding in public health./9
ATDSR appropriations are included within the overall discussion of CDC funding.
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Figure 1. Centers for Disease Control and Prevention Organization Chart
Source: Adapted by CRS from CDC, “CDC Organization Chart,” https://www.cdc.gov/about/organization/ orgchart.htm.
Notes: HIV = Human Immunodeficiency Virus; STD = Sexually Transmitted Disease; TB = Tuberculosis.
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Understanding CDC Appropriations
This CRS report divides CDC‘s annual program level/10 into two categories, as shown in Figure 2:
* core public health program level, funded mostly by annual discretionary Departments of Labor, Health and Human Services, and Education, and Related Agencies (LHHS) appropriations and mandatory Prevention and Public Health Fund (PPHF) appropriations, and
* other mandatory programs, including health services or compensation-related programs funded by program-specific mandatory budget authorities. In addition, CDC receives funding from mandatory user fee programs.
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7 For the purposes of this report, U.S. territories are included in the term, “state,” consistent with the definition of “state” in the PHSA (Section 2, 42 U.S.C. Sec.201).
8 In FY2020, CDC provided more than $6 billion in non-COVID-19-related grant funding into public health programs and research around the world. CDC, “Office of Financial Assistance: FY2020 Assistance Snapshot,” https://www.cdc.gov/funding/documents/fy2020/fy-2020-ofr-snapshot-508.pdf.
9 This report draws from prior year Congressional Budget Justifications and relevant appropriations laws and accompanying reports. See CDC, “Congressional Justifications,” https://www.cdc.gov/budget/congressionaljustifications/index.html.
10 For the purposes of this report, CDC‘s program level is the sum of the agency’s funding for a fiscal year reflecting all sources of budget authority.
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CRS has divided CDC‘s program level into the two categories to allow for valid year-to-year comparisons of programmatic funding levels for the agency. The core public health program level reflects both (1) funding for the main public health program activities conducted by CDC CIOs and ATDSR in support of the agencies’ core missions, and (2) funding that is largely subject to the annual appropriations process, and therefore reflects the legislative decisions made by Congress each year to fund CDC and ATDSR programs. The CDC “core public health program level” for FY2022 in this CRS report aligns with the “CDC/ATDSR program level” presented in FY2023 CDC budget documents./11
The other mandatory programs excluded from the core public health program level have funding levels that are mostly controlled by their program authorizations. The two largest programs – the Vaccines for Children (VFC) program and the World Trade Health Center Program (WTHCP) – primarily finance specific health services for eligible populations. Changes in annual funding reflect usage and demand for the program services. These programs’ funding levels are therefore presented separately from CDC‘s core public health program level and are excluded from analysis of funding trends for the agency’s main programmatic and operating expenses. These other mandatory programs are also generally presented separately from the rest of CDC‘s budget in the agency’s own budget presentations./12
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11 See CDC, “FY2023 Budget Detail Table,” https://www.cdc.gov/budget/documents/fy2023/FY-2023-CDC-BudgetDetail.pdf. CDC changes its budget presentations and categories from year to year.
12 See, for example, CDC, “FY2023 Budget Detail Table,” https://www.cdc.gov/budget/documents/fy2023/FY-2023CDC-Budget-Detail.pdf.
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Figure 2. FY2022 Centers for Disease Control and Prevention Program Level by Category and Budget Authority
Source: CDC, “FY2023 Budget Detail Table,” https://www.cdc.gov/budget/documents/fy2023/FY-2023-CDCBudget-Detail.pdf.
Notes: Acronyms: CDC = Centers for Disease Control and Prevention; WTCHP = World Trade Center Health Program; EEOICPA = Energy Employees Occupational Illness Compensation; VFC = Vaccines for Children; LHHS = Labor, Health and Human Services, Education, and Related Agencies appropriations bill; ATSDR = Agency for Toxic Substances and Disease Registry; PPHF = Prevention and Public Health Fund.
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Core Public Health Program Level
CDC‘s core public health program level funds the main public health programs implemented by CDCs CIOs. Types of funded activities include but are not limited to: developing expertise and best practices in disease prevention and control; conducting and supporting public health research; supporting and conducting public health surveillance and data collection; developing public health laboratory capacity; supporting health education and promotion efforts; coordinating and providing technical assistance to public health programs at the state and local level; supporting some preventive health services programs (e.g., some vaccination and cancer screening programs); and supporting public health emergency preparedness and response efforts. Many of the programs support public health activities at the state and local level./13
CDC‘s core public health program level is made up of (1) discretionary appropriations; (2), mandatory appropriations from the Prevention and Public Health Fund (PPHF); and (3) some other funding sources, such as transfers from other accounts.
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13 See CDC, “Grant Funding Profiles,” https://fundingprofiles.cdc.gov/.
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Discretionary Appropriations. CDC receives funding through annual discretionary LHHS appropriations, while ATSDR is separately funded by Interior/Environment appropriations. Within LHHS appropriations, CDC receives funding in several accounts, many of which have titles that align with the names of CDC CIOs. Some accounts fund activities through multiple CIOs (e.g., Public Health Scientific Services). Some CDC accounts are for agency-wide activities, such as the Buildings and Facilities account and the CDC-Wide Activities and Program Support account.
As an example, the Injury Prevention and Control account funds activities at CDC‘s National Center for Injury Prevention and Control (NCIPC). The appropriations act text provides funding to the Injury Prevention and Control account with respect to such activities as authorized by several PHSA titles as shown in Figure 3.
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Figure 3. Example of CDC Appropriation Language, From FY2021 LHHS Appropriations
Source: Consolidated Appropriations Act, 2021 (P.L. 116-260) Division H, Title II. 134 STAT. 1571.
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Appropriations report language accompanying CDC appropriations generally specifies amounts for programs or activities funded by CDC accounts in greater detail than the appropriations act text. Shown below in Figure 4 is the FY2021 report language and funding table accompanying the Injury Prevention and Control appropriation./14
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14 For a general overview of appropriations report language, see CRS Report R44124, Appropriations Report Language: Overview of Components and Development.
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Figure 4. Example of CDC Appropriations Report Language
Source: “Explanatory Statement Accompanying Consolidated Appropriations Act, 2021,” Congressional Record, vol. 166 (December 21, 2020), p. H8623.
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This CRS report focuses on account-level funding in Table 1. CDC‘s annual Operating Plans reflect programmatic funding levels within accounts as directed by appropriations report language./15
Mandatory Appropriations from the Prevention and Public Health Fund (PPHF). In recent years, some CDC LHHS accounts have received annual allocations of the mandatory PPHF appropriations as directed in LHHS appropriations laws. The PPHF was established in 2010 in Section 4002 the Affordable Care Act (ACA; P.L. 111-148, as amended) “to provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public sector health care costs.”/16
The PPHF has its own appropriation (provided by its authorizing law) and its own account within the HHS Office of the Secretary. In recent years, appropriators have directed specific amounts of annual PPHF funding to specific CDC accounts and programs (in addition to other HHS agencies) through LHHS Appropriations Acts and accompanying report language./17
See Figure 5 for PPHF allocations from FY2021 appropriations.
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15 See CDC, Operating Plans, https://www.cdc.gov/budget/operating-plans/index.html.
16 42 U.S.C. Sec. 300u-11(a).
17 Prior to FY2014, the HHS Secretary determined uses of the PPHF funding. See CRS Report R44796, The ACA Prevention and Public Health Fund: In Brief, by Sarah A. Lister.
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Figure 5. Example of Prevention and Public Health Fund Allocations, From FY2021 LHHS Appropriations
Source: “Explanatory Statement Accompanying Consolidated Appropriations Act, 2021,” Congressional Record, vol. 166 (December 21, 2020), p. H8634.
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As shown in Figure 5, most of the FY2021 PPHF allocation went to CDC. Additional allocations went to the Administration for Community Living (ACL) and the Substance Abuse and Mental Health Services Administration (SAMHSA).
Other funding. CDC sometimes receives funding for its core public health program level through transfers from other sources, including both discretionary and mandatory appropriations, some subject to specific transfer rules.
Transfers. In some years, CDC has received transfers from other HHS accounts or appropriations subject to specific transfer authorities. For example, as shown in Figure 6, CDC has received occasional transfers from the Public Health and Social Services Emergency Fund (PHSSEF)18 and the Nonrecurring Expenses Fund (NEF) accounts./19
In some years, CDC also received LHHS discretionary appropriations under the Public Health Service (PHS) Program Evaluation Set-Aside, or the “PHS evaluation tap” transfer authority. Authorized by PHSA Section 241, the PHS evaluation tap allows the HHS Secretary, with the approval of appropriators, to redistribute a portion of eligible PHS agency appropriations across HHS for program evaluation purposes.
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18 The Public Health and Social Services Emergency Fund is an account of the HHS Secretary that funds several offices and programs including the Administration for Strategic Preparedness and Response (ASPR), the HHS Cybersecurity program, and the Office of National Security. It is also frequently used to provide emergency supplemental appropriations for transfer by the HHS Secretary to agencies in HHS and elsewhere, according to legislative direction.
19 The NEF permits HHS to transfer unobligated balances of expired discretionary funds from FY2008 and subsequent years into the NEF account. Statute authorizes use of the funds for capital acquisitions, including information technology (IT) and facilities infrastructure (42 U.S.C. Sec.3514a). Congress and the President can direct the funds to certain accounts through appropriations acts.
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Recent LHHS Appropriations Acts have established the higher maximum percentage for the set-aside and have distributed specific amounts of “Tap” funding to selected HHS programs. As shown in Figure 6, CDC has not received PHS evaluation tap funding since FY2014. The PHS evaluation tap amounts shown in this CRS report reflect funds as appropriated, but do not reflect final amounts of transfers out of CDC accounts under the same authority.
Smaller mandatory appropriations for public health programs. Some smaller CDC public health programs have been funded by mandatory budget authorities, such as for the Childhood Obesity Demonstration Project,/20 as authorized in Social Security Act (SSA) Section 1139A(e)(8)./21
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Supplemental Appropriations
CDC has also received supplemental appropriations during public health emergencies and other specific incidents, such as during the COVID-19 pandemic, as discussed further in “Supplemental Appropriations for Public Health Emergencies.” Of note, the recently enacted COVID-19 supplemental appropriations and the American Rescue Plan Act (P.L. 117-2) budget reconciliation measure included several major funding streams for general public health capabilities not specific to the pandemic, such as for data modernization. These additional appropriations are discussed in a separate section in this CRS report to distinguish regular appropriations for CDC‘s annual operations from these one-time appropriations.
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Other Mandatory Programs
CDC also administers several health services and compensation programs that are funded by mandatory budget authorities and are distinct from the agency’s core public health programs. In several cases, annual funding levels for these programs are determined by the program’s authorizing law. In addition, CDC receives a small amount of user fees through authorized user fee programs. The Vaccines for Children (VFC) program provides vaccines to enrolled health care providers to vaccinate eligible children./22 As authorized in SSA Section 1928 (42 U.S.C. Sec.1396s), the HHS Secretary can purchase vaccines as necessary for eligible children at a federally negotiated discounted price and then distribute vaccines to participating state and local health departments. State and local health departments then distribute a portion of the supply to participating health care providers and also administer vaccines through their own programs. In addition, some of the annual VFC funding is awarded to states and other jurisdictions for program operations and administration./23 VFC is financed by a Medicaid appropriation within the HHS Centers for Medicare & Medicaid Services (CMS) and is administered by CDC./24 Like other Medicaid programs, VFC is an appropriated entitlement, meaning that VFC funding is provided through LHHS appropriations acts, but the funding level is determined based on budget projections for meeting the funding needs of the program./25
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20 Social Security Act (SSA) Section 1139(e)(8).
21 See, for example, funding for the CDC‘s Childhood Obesity Research Demonstration (CORD) Project was initially authorized through the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA; P.L. 111-3), and $25 million was appropriated for FY2010 through FY2014 through the Affordable Care Act (ACA; P.L. 111-148, as amended) in 2010. CDC, “Report to Congress on the Centers for Disease Control and Prevention’s Childhood Obesity Research Demonstration Project,” https://www.cdc.gov/obesity/downloads/strategies/report-to-congress-CORD508.pdf.
22 VFC is funded by mandatory Medicaid appropriations that are transferred annually to CDC. See 42 U.S.C. Sec. 1396s.
23 See “State Table: Vaccines for Children” in CDC, FY2022 Congressional Budget Justification, pp. 74-75, https://www.cdc.gov/budget/documents/fy2022/FY-2022-CDC-congressional-justification.pdf.
24 Centers for Medicare & Medicaid Services (CMS), FY2023 Congressional Budget Justification, p. 107, https://www.cms.gov/files/document/fy2023-cms-congressional-justification-estimates-appropriations-committees.pdf.
25 See CRS Report R42640, Medicaid Financing and Expenditures.
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The Energy Employees Occupational Illness Compensation Program (EEOICP) provides compensation and medical benefits to eligible civilians (or their survivors) who have performed duties related to the nuclear weapons production and testing programs of the Department of Energy./26 CDC provides support to the program by conducting radiation dose estimates, evaluating certain petitions, and providing other administrative support./27 Annual funding for these CDC activities are generally provided pursuant to Section 151(b) of Division B, Title I of Consolidated Appropriations Act, 2001 (P.L. 106-554), which specifies that annual funding pursuant to that section shall be direct spending (i.e., mandatory appropriations)./28
The World Trade Center Health Program (WTCHP) provides medical monitoring and treatment to eligible individuals directly affected by the September 11, 2001 attacks for certain incident-related health conditions. Furthermore, this program funds medical research into health conditions that may develop due to exposure during the attacks./29 The program is authorized by PHSA Title XXXIII (42 U.S.C. Sec. 300mm et seq.) and funded through mandatory appropriations in PHSA Section 3351 (42 USC Sec.300mm-61).
User fee programs. CDC also receives relatively small amounts of user fees from authorized user fee programs such as the vessel sanitation program/30 and the respirator certification program./31
FY2022 and FY2023 Budget and Appropriations
The following provides an overview of the budget and appropriations for CDC‘s core public health program level in fiscal years 2022 and 2023. Other CDC mandatory appropriations are not addressed in the discussion as most are not subject to the annual appropriations process (except for EEOICP), though estimates and amounts for those programs are summarized in Table 1. However, some notable new mandatory programs proposed by the Biden Administration in FY2023 are discussed below to explain the FY2023 total proposed program level.
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26 CDC, “NIOSH Radiation Dose Reconstruction Program,” https://www.cdc.gov/niosh/ocas/faqsact.html.
27 CDC, “Energy Employees Occupational Illness Compensation Program Act (EEOICPA) Budget Request” in FY2022 Congressional Budget Justification, p. 302, https://www.cdc.gov/budget/documents/fy2022/FY-2022-CDCcongressional-justification.pdf.
28 See, for example, in FY2021 LHHS appropriations, 134 STAT 1571 of Division H, Title II, P.L. 116-260.
29 CDC, “World Trade Center Health Program,” https://www.cdc.gov/wtc/.
30 “The Vessel Sanitation Program (VSP) at the Centers for Disease Control and Prevention (CDC) assists the cruise ship industry to prevent and control the introduction, transmission, and spread of gastrointestinal (GI) illnesses on cruise ships.” Under authority in in PHSA Section 361; 42 U.S.C. Sec. 264. See CDC, “Vessel Sanitation Program,” https://www.cdc.gov/nceh/vsp/default.htm.
31 The respirator certification program conducts assessments and NIOSH approval of particulate filtering facepiece respirators. 42 C.F.R. Part 84. See also CDC, Respirator Certification Fees Schedules,” https://www.cdc.gov/niosh/npptl/respcertfeescheduletables.html.
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FY2022
President Biden submitted a summary of his FY2022 budget request for discretionary funding on April 9, 2021,/32 and subsequently released the full proposal on May 28, 2021. The request sought $9.579 billion for CDC‘s core public health program level, as follows:/33
* $8.455 billion in LHHS discretionary budget authority for CDC,
* $82 million in Interior/Environmental discretionary budget authority for ATDSR,
* $903 million in PPHF funding, and
* $139 million under the PHS evaluation tap authority.
The requested FY2022 program level would have represented a $1.702 billion increase (+21.6%) over CDC‘s final FY2021 core public health program level of $7.877 billion./34 As a significant addition under the FY2022 request, $400 million in new funding would have been provided for core public health infrastructure and capacity in the CDC-Wide Activities and Program Support account. Per the budget request, the goal of the new funding was “to address critical gaps in public health infrastructure and facilitate the transition from sporadic emergency funding to a sustainable model that can respond to ongoing challenges and prevent future crises.”/35
In March 2022, Congress and the President enacted the Consolidated Appropriations Act, 2022 (P.L. 117-103), which provided FY2022 LHHS appropriations in Division H and Interior/Environment appropriations in Division G. The law provided CDC a total core public health program level of $8.482 billion, comprising the following:
* $7.499 billion in LHHS discretionary appropriations for CDC,
* $81 million in Interior/Environment discretionary appropriations for ATSDR, and
* $903 million in mandatory PPHF appropriations.
The FY2022 enacted funding level represented a $606 million (+7.7%) increase from the FY2021 final core public health program level and was $1.1 billion (-11.5%) less than the President’s FY2022 budget request. The requested new Public Health Infrastructure and Capacity appropriation was funded at $200 million in the CDC-Wide Activities and Program Support account – 50% less than proposed in the request.
FY2023
President Biden’s FY2023 budget request for CDC proposes a core public health program level of $38.76 billion made up of the following:/36
* $9.621 billion in LHHS discretionary appropriations for CDC,
* $85 million in Interior/Environment discretionary appropriations for ATSDR,
* $903 million in mandatory PPHF appropriations,
* $151 million subject to the PHS evaluation tap transfer authority, and
* $28 billion in proposed new mandatory public health preparedness funding, available over five years.
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32 Letter from Shalanda D. Young, Office of Management and Budget Acting Director, to The Honorable Patrick Leahy, Chairman Committee on Appropriations, April 9, 2021, https://www.whitehouse.gov/wp-content/uploads/2021/ 04/FY2022-Discretionary-Request.pdf.
33 This report uses budget request numbers from Congressional Record, vol. 168, No. 42, (March 9, 2022), H2860H2862.
34 The final funding level reflects post-appropriations transfers and other adjustments.
35 CDC, Congressional Budget Justification: FY2022, https://www.cdc.gov/budget/documents/fy2022/FY-2022-CDCcongressional-justification.pdf, p. 10.
36 CDC, Congressional Budget Justification: FY2023, https://www.cdc.gov/budget/documents/fy2023/FY-2023-CDCcongressional-justification.pdf.
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This requested FY2023 core public health program level, including the new mandatory public health preparedness funding, represents a $30.277 billion (+356.9%) increase over the FY2022 enacted program level. Of the total increase, 92.5% of the amount is from the new proposed mandatory pandemic preparedness appropriation (explained in the next section). Excluding the pandemic preparedness funding, the proposed core public health program level is $10.675 billion, which would represent a $2.273 billion (+27.1%) increase over the FY2022 enacted program level.
In addition, the request proposes a significant change in how annual discretionary funding is appropriated to CDC. Specifically, the request proposes consolidating 13 CDC LHHS accounts under a single appropriations heading, CDC-Wide Activities and Program Support./37 According to the request, this consolidation would “enable the agency to more easily access all of its resources to address a crisis” and mount a “whole of agency” response to a public health threat./38 This change would return CDC‘s appropriations account structure to that of FY2010 and earlier years when CDC received almost all of its discretionary appropriations under one heading./39
The budget request’s proposed LHHS discretionary appropriations legislative text would provide the $9.621 billion total with a few set-asides specified in law, including $128.4 million for international HIV/AIDS programs, $353.2 million for global health protection, $600 million for public health infrastructure and capacity, and $50 million for forecasting epidemics and analytics (all are existing programs)./40 Separately, CDC has published a detailed budget table for FY2023 by programs, projects, and activities comparable to the current budget structure as shown in Table 1. Per the request, CDC plans to continue to maintain accountability and transparency for “the programs, projects and activities described in Congressional reports.”/41
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37 Accounts consolidated would include: Immunization and Respiratory Diseases, HIV/AIDS, Viral Hepatitis, STI and TB Prevention, Emerging and Zoonotic Infectious Diseases, Chronic Disease Prevention and Health Promotion, Birth Defects, Developmental Disabilities, Disability and Health, Environmental Health, Injury Prevention and Control, Public Health Scientific Services, Global Health, Public Health Preparedness and Response, and Cross-Cutting Activities and Program Support.
38 See 123 Stat 3241 in Consolidated Appropriations Act, 2010, P.L. 111-117.
38 CDC, Congressional Budget Justification: FY2023, p. 31.
39 See 123 Stat 3241 in Consolidated Appropriations Act, 2010, P.L. 111-117.
40 CDC, Congressional Budget Justification: FY2023, p. 36.
41 CDC, Congressional Budget Justification: FY2023, p. 31.
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Pandemic Preparedness Proposal
The FY2023 request proposes an HHS-wide total of $81.7 billion in mandatory appropriations for pandemic preparedness, available for five years, with $28 billion of the total designated for CDC. The new HHS-wide mandatory appropriation – which would be likely authorized and controlled outside of the annual appropriations process – would “support the Administration’s plan to transform U.S. capabilities to prepare for and respond rapidly and effectively to future pandemics and other high consequence biological threats.”/42 Per the request, the CDC appropriation would support domestic and international public health surveillance and data monitoring activities; medical countermeasure distribution networks; public health research, analytics, and forecasting; public health laboratories; and other infrastructure and core capability investments such as for emergency response structures, workforce, and data modernization./43
Other Legislative Proposals
CDC‘s FY2023 budget request also includes several proposed mandatory programs or program changes that would be authorized and likely controlled outside of the annual appropriations process. The amounts shown in Table 1 reflect the following proposals:/44
* Vaccines for Adults Program. According to the request, CDC submitted a legislative proposal for mandatory funding of $25 billion provided over 10 years to establish a new Vaccines for Adults program. The program would provide Advisory Committee on Immunization Practices (ACIP)-recommended vaccines to uninsured adults at no cost. Funded program activities would comprise vaccine purchase, provider fees, and program operations.
* VFC program modifications. CDC proposes expanding eligibility for the VFC program to all children under 19 years of age enrolled in the Children’s Health Insurance Program (CHIP). The proposal would also change the fee structure for providers participating in the program. The FY2023 requested amount for VFC in Table 1 reflects the proposed program modifications. According to the budget request, the FY2023 VFC funding estimate based on current law is $5.609 billion./45
Funding Table
Table 1 provides an overview of CDC/ATSDR budget and appropriations for FY2021 (final/ 46 through the FY2023 budget request, reflecting all sources of regular budget authority (excludes supplemental appropriations).
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42 CDC, Congressional Budget Justification: FY2023, pp. 58-59.
43 CDC, Congressional Budget Justification: FY2023, pp. 58-59.
44 CDC, Congressional Budget Justification: FY2023, pp. 58-59.
45 CDC, FY2023 Budget Detail Table, https://www.cdc.gov/budget/documents/fy2023/FY-2023-CDC-BudgetDetail.pdf.
46 FY2021 final funding level reflects post-enactment transfers and other adjustments.
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Table 1. Centers for Disease Control and Prevention (CDC) and Agency for Toxic Substances and Disease Registry (ATSDR) Appropriations, FY2021-FY2023 Request
Source: FY2021 final amounts, FY2023 request amounts, and mandatory program amounts for all years are from CDC, “FY2023 Budget Detail Table,” https://www.cdc.gov/budget/documents/fy2023/FY-2023-CDCBudget-Detail.pdf. FY2022 enacted discretionary appropriations and FY2022 request discretionary appropriations are from Congressional Record, vol. 168, No. 42, (March 9, 2022), H2860-H2862, except where noted below.
Notes: Individual amounts may not add to subtotals or totals due to rounding. Final amounts for FY2021 differ from enacted funding levels due to transfers and other adjustments. Acronyms: HIV = Human Immunodeficiency Virus; AIDS = Acquired Immunodeficiency Syndrome; STI = Sexually Transmitted Infection; TB = Tuberculosis.
a. The FY2023 request proposes consolidating 13 CDC LHHS discretionary accounts into a single account.
b. The Extending Government Funding and Delivering Emergency Assistance Act (P.L. 117-43), one of the FY2022 continuing resolutions, provided an additional $1.5 million for CDC‘s vessel sanitation program.
c. Provided separately in the Interior/Environment appropriations act. FY2022 enacted amount from Congressional Record, vol. 168, No. 42, (March 9, 2022), H2496. FY2022 request amount from CDC, “FY2022 Budget Detail Table,” https://www.cdc.gov/budget/documents/fy2022/FY-2022-CDC-BudgetDetail.pdf.
d. FY2022 and FY2023 amounts are estimates for VFC. WTCHP, User Fees, and Vaccines for Adults.
e. Per the FY2023 budget request table, all amounts for EEOICPA reflect sequestration and therefore differ from appropriated funding levels.
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Continues with Part 2 of 2
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The report is posted at: https://crsreports.congress.gov/product/pdf/R/R47207
