This is public health. This is public health on sequestration.

by Kim Krisberg

To the long list of hard-to-pronounce bacteria and viruses that threaten people's health can now be added one more threat: sequestration. Except sequestration isn't a disease — well, unless you'd call Congress' chronic inability to deal with the national debt in a fair and balanced way a disease.

Of course, if sequestration were a real disease, the public health system might actually be immune to such budget-slashing illnesses by now, considering its near-constant exposure rate. But come this January, if Congress doesn't act, the public health system will absorb another round of devastating budget cuts. And these cuts will result in real disease and damage. No metaphors needed. These cuts will be bad for people's health.

Sequestration was the fallback plan if Congress failed to come to an agreement on how to address the national debt. The budget-cutting mechanism was included in last year's Budget Control Act, which established the Joint Select Committee on Deficit Reduction and charged it with developing legislation to reduce projected deficits by $1.2 trillion. If the committee failed, the act included a backup plan known as sequestration, an automatic, across-the-board spending cut due to kick in on January 2^nd and go through 2021. Now it’s August, the committee has failed, and sequestration is on the horizon.

Sequestration is a blunt mechanism — the intricacies of which programs are most or least deserving of budget cuts don't matter. Everything's on the chopping block. That means defense spending, too, which seems to be getting most of the media and congressional attention. (House Speaker John Boehner, R-Ohio, has offered to cancel Congress' August recess if the Senate considers a plan to shift the military cuts to domestic programs instead.) But sequestration's effect on public health programs could be catastrophic for the people who depend on them.

According to a report on sequestration released by Sen. Tom Harkin's, D-Iowa, office:

"Nondefense discretionary (NDD) spending already has absorbed significant reductions through the 10‐year spending caps in the Budget Control Act and other measures. By 2021, this category of spending will account for just 2.8 percent of the U.S. gross domestic product, its lowest level in more than 50 years. Today, NDD programs comprise about one-sixth of the Federal budget. It defies not only reason, but also fairness and equality, to suggest that we can erase our national debt by slashing critical priorities like education and medical research while holding Pentagon spending harmless and expecting the wealthiest among us to sacrifice nothing." 

If sequestration takes effect, the report warns that (and this is just a sampling of the impact):

• Five million fewer families will be served via the Maternal and Child Health Block grant, which supports services such as prenatal care, well-child services and efforts to reduce infant mortality and preventable injury.
• More than 12,200 people living with HIV/AIDS will lose access to life-saving drugs because of cuts to the AIDS Drug Assistance Program (ADAP).
• More than 659,000 fewer people will be screened for HIV because of cuts to HIV prevention grants.
• More than 33,800 fewer low-income and uninsured women will be screened for breast and cervical cancer.
• Nearly 212,000 fewer uninsured children will be immunized against preventable diseases.

The American Public Health Association (APHA) also released a fact sheet on the potential impact of sequestration. APHA warns that sequestration cuts to the Centers for Disease Control and Prevention (CDC) budget could:

• Decrease the agency's ability to investigate 100 to 150 multistate outbreaks, including food-borne illness outbreaks of E. coli, salmonella and norovirus. That means outbreaks will last longer and cause more illness and death before they're under control.
• Decrease the number of local health department personnel trained in epidemiology, laboratory and outbreak response by 2,500.
• Eliminate more than 50 projects aimed at preventing and reducing work-related injury and illness, which already cost the country more than $13 billion every year.

As usual, cuts to public health programs won't actually save money in the long run — more sickness and poor health only increase health care spending and reduce productivity. Don Hoppert, APHA's director of government relations, said "pressure is growing for Congress to find a way out of (sequestration)." To avoid the automatic cuts, Congress needs to come up with an alternative proposal to achieve the same amount of savings. They could also agree to a resolution that delays the scheduled cuts, essentially kicking the problem down the road, Hoppert said.

"Sequestration was a back-up plan, a safety valve in case the committee failed," he told me. "Now, Congress needs to come up with a balanced approach that doesn't put the entire burden on nondefense spending."

To make matters worse, in mid-July a subcommittee of the House Appropriations Committee approved a fiscal year 2013 proposal that would cut CDC resources by 11 percent; eliminate funding for the Agency for Healthcare Research and Quality and the Title X family planning program; stop implementation of the Affordable Care Act; and gut the health reform law's Prevention and Public Health Fund. In an apocalyptic version of public health's future, these proposed cuts would be in addition to sequestration. Hoppert noted that CDC's already absorbed a cut of more than $740 million between fiscal years 2010 and 2011.

Fortunately, APHA is among the many public health advocates working to stop this particularly depressing version of the future. APHA's PHACT (Public Health ACTion) Campaign is urging public health supporters to visit their congressional representatives when they return home to their districts during this month's congressional recess and "remind them what these cuts will mean in real terms — how many people will be laid off, how many clinics will close, how many fewer immunizations will be administered." He said public health supporters "can't afford to give up" because the defense sector certainly won't give up trying to stop spending cuts to their priorities.

"Sequestration would be a huge hit to public health," Hoppert said. "And it's local public health workers who can really educate on what those cuts would mean at the community level."

To learn more about the impact of sequestration on public health and to access a copy of the Harkin report, visit APHA's PHACT Campaign page.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for a decade.