First things first: The White House’s budget is not law, nor will its latest iteration likely become law. President Trump’s proposal, released to the public Tuesday, is instead a signaling of his administration’s priorities—which congressional Republicans will likely ignore or heavily edit when they negotiate their own figures.
Still, as has been said ad nauseam since Trump’s initial funding blueprint came out in March, the budget is a moral document. The White House’s plan to trim $3.6 trillion in federal spending over 10 years indicates how the executive branch sees the missions and roles of the various agencies under its purview. And it’s clear from the details that public health is not close to being a top focus under Trump.
Much of the health safety net in the United States is formed by federal departments and agencies. There’s the Department of Health and Human Services, under which fall the Public Health Service, the Centers for Disease Control and Prevention, the National Institutes of Health, and the Centers for Medicare and Medicaid Services, among several other critical public-health structures. There are also some crucial health-related components outside of HHS, including much of the Environmental Protection Agency, the lead-testing program under the Department of Housing and Urban Development, and the Supplemental Nutrition Assistance Program, commonly referred to as food stamps. With few exceptions, the Trump budget would slash these.
HHS would see many of the cuts. The proposed 2018 budget for the department includes plans to trim its funding by over $600 billion over the next decade. Much of that strategy seems designed to compensate for the net effects of Obamacare repeal. The budget presumes Congress will follow through on complete reform, and in the process will slash somewhere in the ballpark of $800 billion from the Medicaid program over the next decade by making changes to its financing structure. In addition to those cuts, the budget would decrease funding to the Children’s Health Insurance Program—which supplements Medicaid coverage for low-income children—by 20 percent.
Among the other programs and agencies targeted within HHS, the Trump plan would trim funding for the National Institutes of Health by close to $6 billion by 2018, the lion’s share of which comes from a $1 billion cut to the National Cancer Institute; an $838 million cut to National Institute of Allergy and Infectious Diseases; a $575 million cut to the National Heart, Lung, and Blood Institute; and a $400 million cut from two institutes devoted to mental health and drug abuse. It’d also slash the Food and Drug Administration’s budget by 30 percent, shave $1 billion from the CDC programs budget, completely defund Planned Parenthood, and decrease funding for mental-health block grants and substance-abuse prevention under the Substance Abuse and Mental Health Services Administration.
These reductions alone would put the health safety net, as well as emergency-response systems, under significant strain—which would in turn be compounded by the extraordinary health crises currently facing the country. Medicaid, CHIP, and Planned Parenthood are the most significant funding and delivery sources of preventative and emergency care for low-income people. On a more macro level, paring back those programs decreases the ability on all levels of government to manage coordinated responses to chronic and infectious diseases. The per-capita cap and block-grant financing scheme for Medicaid under the new budget (and, presumably, under a congressional Obamacare-replacement plan) would put structural limits on states’ capacity to deal with epidemics of either kind.
Additionally, Trump’s budget would curtail cutting-edge research for the most significant drivers of mortality in the country, from heart disease to diabetes to cancer. It would cut back on research for infectious and mosquito-borne diseases, even as they threaten to establish a beachhead in the warming southern United States, and ease up on combating HIV just when some experts finally see a possible end to the pandemic in the future.
Perhaps the most alarming threat now facing Americans’ health is the opioid crisis, and the president’s budget suggests the executive branch is not prepared to fight it. Although it preserves “drug czar” funding—after Trump’s initial suggestion to gut the Office of National Drug Control Policy sparked an outcry—the remainder undermines national efforts to combat opioids. For one, Medicaid is the largest funder of mental-health and substance-abuse treatment, and the proposed cuts to that program’s budget alone would probably be insurmountable in a coordinated, national emergency response.
But Trump would also reduce funding for SAMHSA’s substance-abuse prevention programs, that agency’s mental-health block grants, and NIH-funded research on mental health. That would seem to go against best practices: As is well known in public-health circles, prevention is usually a more cost-effective bet than treatment, and emerging scientific consensus suggests at least some of the opioid crisis stems from the staggering failure of mental-health diagnosis and treatment.
The opioid crisis isn’t the only national health-care emergency, and new issues ever lurk on the horizon. Yet under this budget, the executive branch would not be equipped to face them either. Even as ongoing research reveals the depths to which lead poisoning is underreported, and is both much more ubiquitous and potent than originally considered, Trump’s cuts to the EPA and to lead-amelioration programs would put the country on the back foot. Proposed reductions in anti-poverty programs also run the risk of exacerbating the nutrition and obesity issues that plague much of the country.
Again, the White House’s spending plan isn’t law. It has the luxury of evading hard scrutiny as an ideological and mostly symbolic outline. But in its designs for implementing austerity on a public-health system in deep crisis, the budget reveals not only the president’s and his advisers’ ideology, but also a deep unknowing on their part on how to fix the problems that make and break the country.