Centers for Disease Control and Prevention (CDC) Funding Overview

Centers for Disease Control and Prevention
August 5, 2022March 28, 2023
(CDC) Funding Overview
Kavya Sekar, Coordinator
The Centers for Disease Control and Prevention (CDC) is a federal public health agency that The Centers for Disease Control and Prevention (CDC) is a federal public health agency that
Analyst in Health Policy Analyst in Health Policy
develops and supports community-based and population-wide programs and systems to promote develops and supports community-based and population-wide programs and systems to promote

health health-related quality of life and to prevent the leading causes of disease, injury, disability, and and to prevent the leading causes of disease, injury, disability, and
Hassan Z. Sheikh
death, both domestically and globally. In addition, the Agency for Toxic Substances and Disease death, both domestically and globally. In addition, the Agency for Toxic Substances and Disease
Registry For a copy of the full report, Analyst in Public Health
Registry (ATSDR) is headed by the CDC (ATSDR) is headed by the CDC directorDirector and is tasked with identifying potential public and is tasked with identifying potential public
Emergency Management
health health please call 7-5700 or visit effects from exposure to hazardous substances. This CRS report provides an overview of effects from exposure to hazardous substances. This CRS report provides an overview of

CDC’s CDC’s www.crs.gov. budget and appropriations with a focus on budget and appropriations with a focus on FY2022FY2023 enacted appropriations and the enacted appropriations and the
FY2023 FY2024 President’s budget request. The report also discusses supplemental appropriations for President’s budget request. The report also discusses supplemental appropriations for
Taylor R. Wyatt
CDC and trends in state and local funding for public health. ATDSR appropriations are included CDC and trends in state and local funding for public health. ATDSR appropriations are included
Analyst in Public Health
within the overall discussion of CDC funding. within the overall discussion of CDC funding.
Emergency Management

This report divides CDC’s This report divides CDC’s program level,, or annual funding from all sources of budget authority, or annual funding from all sources of budget authority,
For a copy of the full report,
into two categories, with a focus on the first: into two categories, with a focus on the first:
please call 7-5700 or visit
www.crs.gov.
1. a core public health program level that funds most of the agency’s main public health 1. a core public health program level that funds most of the agency’s main public health
programs. This is made up of programs. This is made up of discretionary and mandatory appropriations that are mostly provided or allocated 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) through the Departments of Labor, Health and Human Services, and Education, and Related Agencies (LHHS)
appropriations act, and appropriations act, and
2. other mandatory programs that include several CDC-administered health services, compensation-related, and user 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 fee programs. These include the World Trade Center Health Program and user fees for cruise ship inspection, among
others. others.
CDC’s enacted CDC’s enacted FY2022FY2023 (P.L. 117- (P.L. 117-103328) core public health program level is $) core public health program level is $8.4829.269 billion, which represents a $ billion, which represents a $606787 million million
(+(+7.79.3%) increase from the %) increase from the FY2021FY2022 final core public health program level 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. The Biden Administration has proposed an FY2024 CDC program level of $11.667 billion, a proposed increase of $2.398 billion over the FY2023 enacted program level. The Biden Administration has separately proposed a new $20 billion in mandatory appropriations for pandemic pandemic preparedness available for five years, of which $6.1 billion would be for CDC. Accounting for the proposed mandatory pandemic preparedness appropriation of $28 billion. Excluding the pandemic
preparedness fundingpreparedness funding, the proposed in the FY2024-requested core public health program level core public health program level is $10.675 billion, which would represent a $2.273
billion (+27.1%) increase over the FY2022total, CDC would receive an increase of $8.498 billion (+91.7%) over the FY2023 enacted program level. enacted program level.
From FY2011 to FY2021, CDC’s core public health funding level has remained between approximately $6.5 and $8 billion From FY2011 to FY2021, CDC’s core public health funding level has remained between approximately $6.5 and $8 billion
until the until the increaseincreases provided in FY2022 provided in FY2022 and FY2023 (not adjusted for inflation). The lowest funding level of $6.28 billion in 2013 included (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 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 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, 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 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 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.) regular operating expenses and programs of the agency.)
In the United States, In the United States, most public health activities are carried out by state and local governmentsstate and local governments are at the forefront of public health. A large portion of CDC’s . 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 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 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 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 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. indicate that public health funding at the state and local level has remained flat or declined over the past decade.
Congressional Research Service Congressional Research Service

---

link to page 4 link to page link to page 4 link to page 56 link to page link to page 78 link to page link to page 1112 link to page link to page 1213 link to page 13 link to page link to page 13 link to page 1314 link to page link to page 1415 link to page 15 link to page link to page 15 link to page 1516 link to page link to page 1718 link to page 19 link to page 19 link to page link to page 19 link to page 19 link to page 2021 link to page 22 link to page link to page 22 link to page 2223 link to page link to page 2425 link to page link to page 56 link to page link to page 78 link to page link to page 78 link to page link to page 89 link to page link to page 910 link to page link to page 1011 link to page link to page 1819 link to page link to page 2324 link to page link to page 2324 link to page link to page 1517 link to page link to page 1517 link to page link to page 2122 link to page link to page 2627 Centers for Disease Control and Prevention (CDC) Funding Overview

Contents
Introduction ..................................................................................................................................... 1
Understanding CDC Appropriations ............................................................................................... 23
Core Public Health Program Level ........................................................................................... 45
Other Mandatory Programs ....................................................................................................... 89
FY2022 and FY2023-FY2024 Budget and Appropriations ............................................................................... 10 9
FY2022 .................................................................................................................................... 10
FY2023 Budget Request .......................................................................................................... 11 FY2023 Enacted ............................. 10
Pandemic Preparedness Proposal ......................................................................................... 11
Other Legislative Proposals 12 FY2024 Request ...................................................................................................................... 12
Funding Table ................................................................................................................... 1213
Trends in Core Public Health Program Level................................................................................ 1415
CDC Budget in Context ................................................................................................................ 16
Supplemental Appropriations for Public Health Emergencies and Other Incidents ............... 16
CDC Infectious Diseases Rapid Response Reserve Fund ................................................ 1718
State and Local Funding for Public Health ............................................................................. 19
Trends ............................................................................................................................... 1920
Other Funding-Related Challenges ................................................................................... 2122

Figures
Figure 1. Centers for Disease Control and Prevention Organization Chart ..................................... 23
Figure 2. FY2022FY2023 Enacted Centers for Disease Control and Prevention Program Level by
Category and Budget Authority .................................................................................................... 45
Figure 3. Example of CDC Appropriation Language ...................................................................... 56
Figure 4. Example of CDC Appropriations Report Language ........................................................ 67
Figure 5. Example of Prevention and Public Health Fund Allocations ........................................... 78
Figure 6. Trends in Core Public Health Program Level ................................................................ 1516
Figure 7. Inflation-adjusted Trends in State Spending on Public Health by Category Per
Capita from Alfonso, Leider, and Resnick, et al. (2021). .............................................................................................. 21 20

Tables
Table 1. Centers for Disease Control and Prevention (CDC) and Agency for Toxic
Substances and Disease Registry (ATSDR) Appropriations, FY2021-FY2023FY2022-FY2024 Request ........... 1214
Table 2. Appropriations History to the IDRRRF Account ......................................................................... 18.. 19

Contacts
Author Information ........................................................................................................................ 2324

Congressional Research Service Congressional Research Service

---

link to page link to page 56 Centers for Disease Control and Prevention (CDC) Funding Overview

Introduction
The Centers for Disease Control and Prevention (CDC)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 works to protect public health by providing leadership, information, and scientific expertise in preventing and controlling diseases, including outbreaks of infectious diseases. The CDC also works to promote health and quality of life, by supporting and undertaking efforts that aim to prevent and control injury, disability, and environmental health threats. Its stated mission . Its stated mission
is to “protect America from health, safety and security threats, both foreign and in the [United 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 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 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 in other disease outbreaks and public health emergencies. The Agency for Toxic Substances and
Disease Registry (ATSDR),Disease Registry (ATSDR), a separate operating division headed by the CDC headed by the CDC directorDirector, is tasked with identifying potential , is tasked with identifying potential
public health effects from exposure to hazardous substances. public health effects from exposure to hazardous substances.
Two features characterize CDC’s mission and programs. First, CDC programs tend to focus on 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 of adverse health outcomes, rather than treatment or clinical care after a health issue
arises. Second, CDC programs arises. Second, CDC programs focuspromote health on a on a population and community-wide health interventions,
rather than those that serve individualsbasis. CDC also administers some health services and . CDC also administers some health services and
compensation-related programs as discussed later in this report. CDC is organized into a number compensation-related programs as discussed later in this report. CDC is organized into a number
of centers, institutes and offices (CIOs) as shown of centers, institutes and offices (CIOs) as shown inin Figure 1. Some Some of these CIOs focus on of these CIOs focus on
specific public health challenges (e.g., injury prevention), while others focus on general public specific public health challenges (e.g., injury prevention), while others focus on general public
health capabilities (e.g., surveillance and laboratory health capabilities (e.g., surveillance and laboratory services).2 CDC was established in 1946 as the Communicable Disease Center.3 Under authority provided by congressionally approved reorganization plans, CDC has since been reorganized and renamed.4 Most of CDC’s programs are authorizedservices).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). in the Public Health Service Act (PHSA).5 Many CDC Many CDC
programs and activities are not explicitly programs and activities are not explicitly authorized but are based inmentioned in the PHSA, but CDC carries out those programs on the basis of general and permanent general and permanent
statutory authorities statutory authorities of the HHS Secretary, mostly in the PHSA.3 Four CDC CIOs4granted to the HHS 1 Centers for Disease Control and Prevention (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 CDC, “Our History-Our Story,” https://www.cdc.gov/about/history/index.html. 4 CRS In Focus IF12241, The Centers for Disease Control and Prevention (CDC), and Institute of Medicine (now National Academy of Medicine), “Appendix H Statutory Framework for the Organization and Management of the U.S. Department of Health and Human Services,” in HHS in the 21st Century: Charting a Course for a Healthier America, 2009, pp. 209-219. 5 For more information, see CRS In Focus IF12241, The Centers for Disease Control and Prevention (CDC). Congressional Research Service 1 Centers for Disease Control and Prevention (CDC) Funding Overview Secretary.6 Four CDC CIOs7 and numerous and numerous
specific CDC specific CDC programs5programs8 are explicitly authorized. CDC also has certain regulatory are explicitly authorized. CDC also has certain regulatory
responsibilities.responsibilities.69
Given CDC’s mix of general and specific authorizations, appropriations play a central role in Given CDC’s mix of general and specific authorizations, appropriations play a central role in
guiding the agency’s policy priorities. guiding the agency’s policy priorities.

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 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 state10 and local health departments.11 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 FY2022 to FY2024 and its funding history for core public health programs from FY2011 to FY2024. 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.12 ATDSR appropriations are included within the overall discussion of CDC funding. 6 For example, PHSA Section 301 (42 U.S.C. §241) authorizes the HHS Secretary to conduct and support health- For example, PHSA Section 301 (42 U.S.C. §241) authorizes the HHS Secretary to conduct and support health-
related research and investigations. PHSA Section 317 (42 U.S.C. §247b) authorizes the Secretary to award grants to related research and investigations. PHSA Section 317 (42 U.S.C. §247b) authorizes the Secretary to award grants to
states for preventive health programs, and PHSA Section 319 (42 U.S.C. §247d) authorizes the Secretary to respond to states for preventive health programs, and PHSA Section 319 (42 U.S.C. §247d) authorizes the Secretary to respond to
public health emergencies. public health emergencies.
47 Explicitly authorized CDC components include the National Institute for Occupational Safety and Health (NIOSH), 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. §§651 et seq.); the National Center on Birth authorized by the Occupational Safety and Health Act of 1970 (29 U.S.C. §§651 et seq.); the National Center on Birth
Defects and Developmental Disabilities (NCBDDD) established in PHSA Section 317C (42 U.S.C. §247b-4); the Defects and Developmental Disabilities (NCBDDD) established in PHSA Section 317C (42 U.S.C. §247b-4); the
National Center for Health Statistics (NCHS) established in PHSA Section 306 (42 U.S.C. §242k); and the Agency for National Center for Health Statistics (NCHS) established in PHSA Section 306 (42 U.S.C. §242k); and the Agency for
Toxic Substances and Disease Registry (ATSDR) established by the Comprehensive Environmental Response, 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. §§9601 et seq.). Compensation and Liability Act of 1980 (CERCLA, the “Superfund” law; 42 U.S.C. §§9601 et seq.).
58 Among numerous others, PHSA Sections 317A et seq. authorize lead poisoning prevention activities, and PHSA Title Among numerous others, PHSA Sections 317A et seq. authorize lead poisoning prevention activities, and PHSA Title
XXXIII authorizes the World Trade Center Health Program. XXXIII authorizes the World Trade Center Health Program.
69 See CDC, “CDC Regulations,” https://www.cdc.gov/regulations/index.html. See CDC, “CDC Regulations,” https://www.cdc.gov/regulations/index.html.
Congressional Research Service

1

---

link to page 7 link to page 7
Centers for Disease Control and Prevention (CDC) Funding Overview

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 state7 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.
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: 10 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. §201). 11 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. 12 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/congressional-justifications/index.html. Congressional Research Service 2 link to page 8 Centers for Disease Control and Prevention (CDC) Funding Overview Figure 1. Centers for Disease Control and Prevention Organization Chart Source: Adapted by CRS from CDC, “CDC Organization Chart,” https://www.cdc.gov/about/pdf/organization/cdc-org-chart.pdf, updated as of February 23, 2023. Notes: HIV = Human Immunodeficiency Virus; STD = Sexually Transmitted Disease; TB = Tuberculosis. HIV = Human Immunodeficiency Virus; STD = Sexually Transmitted Disease; TB = Tuberculosis.
Understanding CDC Appropriations
This CRS report divides CDC’s annual This CRS report divides CDC’s annual program level10level13 into two categories, as shown i into two categories, as shown in Figure
2:

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. §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/congressional-
justifications/index.html.
102. 13 For the purposes of this report, CDC’s program level is the sum of the agency’s funding for a fiscal year reflecting all 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. sources of budget authority.
Congressional Research Service Congressional Research Service

23

---

Centers for Disease Control and Prevention (CDC) Funding Overview

 core public health program level, funded mostly by annual discretionary  core public health program level, funded mostly by annual discretionary
Departments of Labor, Health and Human Services, and Education, and Related Departments of Labor, Health and Human Services, and Education, and Related
Agencies (LHHS) appropriations and mandatory Prevention and Public Health Agencies (LHHS) appropriations and mandatory Prevention and Public Health
Fund (PPHF) appropriations, and Fund (PPHF) appropriations, and
 other mandatory programs, including health services or compensation-related  other mandatory programs, including health services or compensation-related
programs funded by program-specific mandatory budget authorities. In addition, programs funded by program-specific mandatory budget authorities. In addition,
CDC receives funding from mandatory user fee programs. CDC receives funding from mandatory user fee programs.
CRS has divided CDC’s program level into the two categories to allow for valid year-to-year 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 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 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 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 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 Congress each year to fund CDC and ATDSR programs. The CDC “core public health program
level” for level” for FY2022FY2023 in this CRS report aligns with the “CDC/ATDSR program level” presented in in this CRS report aligns with the “CDC/ATDSR program level” presented in
FY2023FY2024 CDC budget documents. CDC budget documents.1114
The other mandatory programs excluded from the core public health program level have funding 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 levels that are mostly controlled by their program authorizations. The two largest programs—the
Vaccines for Children (VFC) program and the World Trade Vaccines for Children (VFC) program and the World Trade Health CenterCenter Health Program ( Program (WTHCPWTCHP)—)—
primarily finance specific health services for eligible populations. Changes in annual primarily finance specific health services for eligible populations. Changes in annual fundingspending
reflect usage and demand for the program services. These programs’ funding levels are therefore 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 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 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 other mandatory programs are also generally presented separately from the rest of CDC’s budget
in the agency’s own budget presentations.in the agency’s own budget presentations.12

15
1114 See CDC, “ See CDC, “FY2023FY2024 Budget Detail Table,” https://www.cdc.gov/budget/documents/ Budget Detail Table,” https://www.cdc.gov/budget/documents/fy2023/FY-2023fy2024/FY-2024-CDC-Budget--CDC-Budget-
Detail.pdf. CDC changes its budget presentations and categories from year to year. Detail.pdf. CDC changes its budget presentations and categories from year to year.
1215 See, for example, CDC, “ See, for example, CDC, “FY2023FY2024 Budget Detail Table,” https://www.cdc.gov/budget/documents/ Budget Detail Table,” https://www.cdc.gov/budget/documents/fy2023/FY-2023fy2024/FY-2024--
CDC-Budget-Detail.pdf. CDC-Budget-Detail.pdf.
Congressional Research Service Congressional Research Service

34

---

Centers for Disease Control and Prevention (CDC) Funding Overview

Figure 2. FY2022FY2023 Enacted Centers for Disease Control and Prevention Program Level by
Category and Budget Authority
Thousands of Dollars Thousands of Dollars

Source: FY2023 Enacted numbers from CDC, “FY2024CDC, “FY2023 Budget Detail Table,” https://www.cdc.gov/budget/documents/ Budget Detail Table,” https://www.cdc.gov/budget/documents/fy2023/FY-2023fy2024/FY-2024-CDC--CDC-
Budget-Detail.pdf. Budget-Detail.pdf.
Notes: Amounts reflect some post-appropriations adjustments. Acronyms: CDC = Centers for Disease Control and Prevention; WTCHP = World Trade Center Acronyms: CDC = Centers for Disease Control and Prevention; WTCHP = World Trade Center
Health Program; EEOICPA = Energy Employees Occupational Il ness Compensation; VFC = Vaccines for Health Program; EEOICPA = Energy Employees Occupational Il ness Compensation; VFC = Vaccines for
Children; LHHS = Labor, Health and Human Services, Education, and Related Agencies appropriations bil ; Children; LHHS = Labor, Health and Human Services, Education, and Related Agencies appropriations bil ;
ATSDR = Agency for Toxic Substances and Disease Registry; PPHF = Prevention and Public Health Fund. ATSDR = Agency for Toxic Substances and Disease Registry; PPHF = Prevention and Public Health Fund.
Core Public Health Program Level
CDC’s core public health program level funds the main public health programs implemented by 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 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 best practices in disease prevention and control; conducting and supporting public health
research; supporting and conducting public health surveillance and data collection; developing research; supporting and conducting public health surveillance and data collection; developing
public health laboratory capacity; supporting health education and promotion efforts; public health laboratory capacity; supporting health education and promotion efforts;
coordinating and providing technical assistance to public health programs at the state and local 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 level; supporting some preventive health services programs (e.g., some vaccination and cancer
screening programs); and supporting public health emergency preparedness and response efforts. 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.Many of the programs support public health activities at the state and local level.1316
CDC’s core public health program level is made up of (1) discretionary appropriations; (2), 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 mandatory appropriations from the Prevention and Public Health Fund (PPHF); and (3) some
other funding sources, such as transfers from other accounts. other funding sources, such as transfers from other accounts.

1316 See CDC, “Grant Funding Profiles,” https://fundingprofiles.cdc.gov/. See CDC, “Grant Funding Profiles,” https://fundingprofiles.cdc.gov/.
Congressional Research Service Congressional Research Service

45

---

link to page link to page 89 link to page link to page 910
Centers for Disease Control and Prevention (CDC) Funding Overview

Discretionary Appropriations. CDC receives funding through annual discretionary LHHS CDC receives funding through annual discretionary LHHS
appropriations, while ATSDR is separately funded by Interior/Environment appropriations. appropriations, while ATSDR is separately funded by Interior/Environment appropriations.
Within LHHS appropriations, CDC receives funding in several accounts, many of which have 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 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 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 activities, such as the Buildings and Facilities account and the CDC-Wide Activities and Program
Support account. Support account.
As an example, the Injury Prevention and Control account funds activities at CDC’s National 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 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 to the Injury Prevention and Control account with respect to such activities as authorized by
several PHSA titles as shown iseveral PHSA titles as shown in Figure 3.
Figure 3. Example of CDC Appropriation Language
From From FY2021FY2023 LHHS Appropriations LHHS Appropriations

Source: Consolidated Appropriations Act, Consolidated Appropriations Act, 2021 (P.L. 116-260)2023, P.L. 117-328; Division H, Title II. Division H, Title II. 134 STAT. 1571.
Appropriations report language accompanying CDC appropriations generally specifies amounts Appropriations report language accompanying CDC appropriations generally specifies amounts
for programs or activities funded by CDC accounts in greater detail than the appropriations act for programs or activities funded by CDC accounts in greater detail than the appropriations act
text. Shown below itext. Shown below in Figure 4 is the is the FY2021FY2023 report language and funding table accompanying report language and funding table accompanying
the Injury Prevention and Control appropriation.the Injury Prevention and Control appropriation.1417

1417 For a general overview of appropriations report language, see CRS Report R44124, For a general overview of appropriations report language, see CRS Report R44124, Appropriations Report
Language: Overview of Components and DevelopmentDevelopment and Components. .
Congressional Research Service Congressional Research Service

56

---

link to page link to page 1517 link to page link to page 1011
Centers for Disease Control and Prevention (CDC) Funding Overview

Figure 4. Example of CDC Appropriations Report Language

Source: “Explanatory Statement Accompanying Consolidated Appropriations Act, “Explanatory Statement Accompanying Consolidated Appropriations Act, 20212023,” ,” Congressional Record, ,
vol. vol. 166168 (December (December 21, 2020), p. H862320, 2022), p. S8880. .
This CRS report focuses on account-level funding This CRS report focuses on account-level funding in Table 1. CDC’s annual DC’s annual Operating Plans
reflect programmatic funding levels within accounts as directed by appropriations report reflect programmatic funding levels within accounts as directed by appropriations report
language.language.1518
Mandatory Appropriations from the Prevention and Public Health Fund (PPHF). In recent In recent
years, some CDC LHHS accounts have received annual allocations of the mandatory PPHF 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 appropriations as directed in LHHS appropriations laws. The PPHF was established in 2010 in
Section 4002 Section 4002 of the Affordable Care Act (ACA; P.L. 111-148, as amended) “to provide for expanded 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 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.”help restrain the rate of growth in private and public sector health care costs.”1619 The PPHF has its The PPHF has its
own appropriation (provided by its authorizing law) and its own account within the HHS Office 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 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 funding to specific CDC accounts and programs (in addition to other HHS agencies) through
LHHS Appropriations Acts and accompanying report language.LHHS Appropriations Acts and accompanying report language.1720 See Figure 5 for PPHF for PPHF
allocations from allocations from FY2021FY2023 appropriations. appropriations.

1518 See CDC, See CDC, Operating Plans, https://www.cdc.gov/budget/operating-plans/index.html. https://www.cdc.gov/budget/operating-plans/index.html.
1619 42 U.S.C. § 300u-11(a). 42 U.S.C. § 300u-11(a).
1720 Prior to FY2014, the HHS Secretary determined uses of the PPHF funding. See CRS Report R44796, 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. , by Sarah A. Lister.
Congressional Research Service Congressional Research Service

67

---

link to page link to page 1011 link to page link to page 1819 link to page link to page 1819
Centers for Disease Control and Prevention (CDC) Funding Overview

Figure 5. Example of Prevention and Public Health Fund Allocations
From From FY2021FY2023 LHHS Appropriations LHHS Appropriations

Source: “Explanatory Statement Accompanying Consolidated Appropriations Act, “Explanatory Statement Accompanying Consolidated Appropriations Act, 20212023,” ,” Congressional Record, ,
vol. vol. 166168 (December (December 21, 2020), p. H863420, 2022), p. S8895. .
As shown i As shown in Figure 5, most of the ost of the FY2021FY2023 PPHF allocation went to CDC. Additional allocations PPHF allocation went to CDC. Additional allocations
went to the Administration for Community Living (ACL) and the Substance Abuse and Mental went to the Administration for Community Living (ACL) and the Substance Abuse and Mental
Health Services Administration (SAMHSA). Health Services Administration (SAMHSA).
Other funding. CDC sometimes receives funding for its core public health program level CDC sometimes receives funding for its core public health program level
through transfers from other sources, including both discretionary and mandatory appropriations, through transfers from other sources, including both discretionary and mandatory appropriations,
some subject to specific transfer rules. some subject to specific transfer rules.
Transfers. In some years, CDC has received transfers from other HHS accounts or appropriations In some years, CDC has received transfers from other HHS accounts or appropriations
subject to specific transfer authorities. For example, as shown insubject to specific transfer authorities. For example, as shown in Figure 6, CDC has received DC has received
occasional transfers from the Public Health and Social Services Emergency Fund (PHSSEF)occasional transfers from the Public Health and Social Services Emergency Fund (PHSSEF)1821
and the Nonrecurring Expenses Fund (NEF) accounts.and the Nonrecurring Expenses Fund (NEF) accounts.1922 In some years, CDC also received In some years, CDC also received LHHS
discretionary appropriationstransfers under the Public Health Service (PHS) Program Evaluation Set- under the Public Health Service (PHS) Program Evaluation Set-
Aside, or the “PHS evaluation tap” transfer authority. Authorized by PHSA Section 241, the PHS 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 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. portion of eligible PHS agency appropriations across HHS for program evaluation purposes.
Recent LHHS Appropriations Acts have established the higher maximum percentage for the set-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 aside and have distributed specific amounts of “Tap” funding to selected HHS programs. As
shown inin Figure 6, CDCCDC has not received PHS evaluation tap funding since FY2014. The PHS has not received PHS evaluation tap funding since FY2014. The PHS
evaluation tap
1821 The Public Health and Social Services Emergency Fund is an account of the HHS Secretary that funds several offices 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 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 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. appropriations for transfer by the HHS Secretary to agencies in HHS and elsewhere, according to legislative direction.
1922 The NEF permits HHS to transfer unobligated balances of expired discretionary funds from FY2008 and subsequent 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 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. §3514a). Congress and the President can direct the funds to technology (IT) and facilities infrastructure (42 U.S.C. §3514a). Congress and the President can direct the funds to
certain accounts through appropriations acts. certain accounts through appropriations acts.
Congressional Research Service Congressional Research Service

78

---

link to page 19 link to page 19 link to page 19 link to page 19 Centers for Disease Control and Prevention (CDC) Funding Overview

evaluation tap amounts shown in this CRS report reflect amounts shown in this CRS report reflect funds as appropriatedthe transfer of those funds as directed in appropriations acts, but do not reflect , but do not reflect
final amounts of transfers out of CDC accounts under the same authority. final amounts of transfers out of CDC accounts under the same authority.
Smaller mandatory appropriations for public health programs. Some smaller CDC public health Some smaller CDC public health
programs have been funded by mandatory budget authorities, such as for the Childhood Obesity programs have been funded by mandatory budget authorities, such as for the Childhood Obesity
Demonstration Project,Demonstration Project,2023 as authorized in Social Security Act (SSA) Section 1139A(e)(8). as authorized in Social Security Act (SSA) Section 1139A(e)(8).2124
Supplemental Appropriations
CDC has also received supplemental appropriations during public health emergencies and other specific incidents, CDC has also received supplemental appropriations during public health emergencies and other specific incidents,
such as during the COVID-19 pandemic, as discussed further insuch 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 f 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 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 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 are discussed in a separate section in this CRS report to distinguish regular appropriations for CDC’s annual
operations from these one-time appropriations. operations from these one-time appropriations.
Other Mandatory Programs
CDC also administers several health services and compensationCDC also administers several health services and compensation-related programs that are funded by programs that are funded by
mandatory budget authorities and are distinct from the agency’s core public health programs. In 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 lawseveral cases, the program’s authorizing law determines annual funding levels for these programs. In addition, CDC receives a small amount of user fees through authorized user . In addition, CDC receives a small amount of user fees through authorized user
fee programs. fee programs.
The Vaccines for Children (VFC) program provides vaccines to enrolled health care providers provides vaccines to enrolled health care providers
to vaccinate eligible children.to vaccinate eligible children.2225 As authorized in SSA Section 1928 (42 U.S.C. §1396s), the HHS As authorized in SSA Section 1928 (42 U.S.C. §1396s), the HHS
Secretary can purchase vaccines as necessary for eligible children at a federally negotiated 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. 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 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 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 annual VFC funding is awarded to states and other jurisdictions for program operations and
administration.administration.2326 VFC is financed by a Medicaid appropriation within the HHS Centers for VFC is financed by a Medicaid appropriation within the HHS Centers for
Medicare & Medicaid Services (CMS) and is administered by CDC.Medicare & Medicaid Services (CMS) and is administered by CDC.2427 Like other Medicaid Like other Medicaid
programs, VFC is an appropriated entitlement, meaning that VFC funding is provided through 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 LHHS appropriations acts, but the funding level is determined based on budget projections for
meeting the funding needs of the program.meeting the funding needs of the program.2528

2023 Social Security Act (SSA) Section 1139(e)(8). Social Security Act (SSA) Section 1139(e)(8).
2124 See, for example, funding for the CDC’s Childhood Obesity Research Demonstration (CORD) Project was initially 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 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 $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 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-CORD-Research Demonstration Project,” https://www.cdc.gov/obesity/downloads/strategies/report-to-congress-CORD-
508.pdf. 508.pdf.
2225 VFC is funded by mandatory Medicaid appropriations that are transferred annually to CDC. See 42 U.S.C. § 1396s. VFC is funded by mandatory Medicaid appropriations that are transferred annually to CDC. See 42 U.S.C. § 1396s.
2326 See “State Table: Vaccines for Children” in CDC, See “State Table: Vaccines for Children” in CDC, FY2022 Congressional Budget Justification, pp. 74-75, pp. 74-75,
https://www.cdc.gov/budget/documents/fy2022/FY-2022-CDC-congressional-justification.pdf. https://www.cdc.gov/budget/documents/fy2022/FY-2022-CDC-congressional-justification.pdf.
2427 Centers for Medicare & Medicaid Services (CMS), Centers for Medicare & Medicaid Services (CMS), FY2023 Congressional Budget Justification, p. 107, p. 107,
https://www.cms.gov/files/document/fy2023-cms-congressional-justification-estimates-appropriations-committees.pdf. https://www.cms.gov/files/document/fy2023-cms-congressional-justification-estimates-appropriations-committees.pdf.
2528 See CRS Report R42640, See CRS Report R42640, Medicaid Financing and Expenditures. .
Congressional Research Service Congressional Research Service

89

---

link to page link to page 1517 Centers for Disease Control and Prevention (CDC) Funding Overview

The Energy Employees Occupational Illness Compensation Program (EEOICP) provides provides
compensation and medical benefits to eligible civilians (or their survivors) who have performed 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 duties related to the nuclear weapons production and testing programs of the Department of
Energy.Energy.2629 CDC provides support to the program by conducting radiation dose estimates, CDC provides support to the program by conducting radiation dose estimates,
evaluating certain petitions, and providing other administrative support.evaluating certain petitions, and providing other administrative support.2730 Annual funding for Annual funding for
these CDC activities are generally provided pursuant to Section 151(b) of Division B, Title I of 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 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).pursuant to that section shall be direct spending (i.e., mandatory appropriations).2831
The World Trade Center Health Program (WTCHP) provides medical monitoring and provides medical monitoring and
treatment to eligible individuals directly affected by the September 11, 2001 attacks for certain 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 incident-related health conditions. Furthermore, this program funds medical research into health
conditions that may develop due to exposure during the attacks.conditions that may develop due to exposure during the attacks.2932 The program is authorized by The program is authorized by
PHSA Title XXXIII (42 U.S.C. § 300mm et seq.) and funded through mandatory appropriations PHSA Title XXXIII (42 U.S.C. § 300mm et seq.) and funded through mandatory appropriations
in PHSA Section 3351 (42 USC §300mm–61). in PHSA Section 3351 (42 USC §300mm–61).
User fee programs. CDC also receives relatively small amounts of user fees from authorized CDC also receives relatively small amounts of user fees from authorized
user fee programs such as the vessel sanitation user fee programs such as the vessel sanitation program30program33 and the respirator certification and the respirator certification
program.program.3134
FY2022 and FY2023-FY2024 Budget and Appropriations
The following provides an overview of the budget and appropriations for CDC’s core public The following provides an overview of the budget and appropriations for CDC’s core public
health program level in fiscal years 2022 health program level in fiscal years 2022 and 2023through 2024. Other CDC mandatory appropriations are not . Other CDC mandatory appropriations are not
addressed in the discussion as most are not subject to the annual appropriations process (except addressed in the discussion as most are not subject to the annual appropriations process (except
for EEOICP)for EEOICP), though estimates. Estimates and amounts for those programs are summarized and amounts for those programs are summarized in in Table 1.
However, some notable new mandatory programs proposed by the Biden Administration in However, some notable new mandatory programs proposed by the Biden Administration in
FY2023 FY2023 are discussed below to explain the FY2023 total proposed program level.

26and FY2024 requests are explained. FY2022 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, 29 CDC, “NIOSH Radiation Dose Reconstruction Program,” https://www.cdc.gov/niosh/ocas/faqsact.html. CDC, “NIOSH Radiation Dose Reconstruction Program,” https://www.cdc.gov/niosh/ocas/faqsact.html.
2730 CDC, “Energy Employees Occupational Illness Compensation Program Act (EEOICPA) Budget Request” in 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-CDC-FY2022 Congressional Budget Justification, p. 302, https://www.cdc.gov/budget/documents/fy2022/FY-2022-CDC-
congressional-justification.pdf. congressional-justification.pdf.
2831 See, for example, in FY2021 LHHS appropriations, 134 STAT 1571 of Division H, Title II, P.L. 116-260. See, for example, in FY2021 LHHS appropriations, 134 STAT 1571 of Division H, Title II, P.L. 116-260.
2932 CDC, “World Trade Center Health Program,” https://www.cdc.gov/wtc/. CDC, “World Trade Center Health Program,” https://www.cdc.gov/wtc/.
3033 “The Vessel Sanitation Program (VSP) at the Centers for Disease Control and Prevention (CDC) assists the cruise “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 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. §cruise ships.” Under authority in in PHSA Section 361; 42 U.S.C. § 264. See CDC, “Vessel Sanitation Program,” 264. See CDC, “Vessel Sanitation Program,”
https://www.cdc.gov/nceh/vsp/default.htm. https://www.cdc.gov/nceh/vsp/default.htm.
3134 The respirator certification program conducts assessments and NIOSH approval of particulate filtering facepiece 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/respirators. 42 C.F.R. Part 84. See also CDC, Respirator Certification Fees Schedules,” https://www.cdc.gov/niosh/
npptl/respcertfeescheduletables.html. npptl/respcertfeescheduletables.html.
Congressional Research Service Congressional Research Service

910

---

link to page 17 Centers for Disease Control and Prevention (CDC) Funding Overview

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 $81 million in Interior/Environment discretionary appropriations for ATSDR, and  $903 million in mandatory PPHF appropriations. FY2023 Budget Request President Biden’s FY2023 budget request for CDC would have provided a core public health program level core public health program level, as follows:33
 $8.455 of $38.76 billion made up of the following:35  $9.621 billion in LHHS discretionary billion in LHHS discretionary budget authorityappropriations for CDC, for CDC,
 $ $8285 million in Interior/ million in Interior/EnvironmentalEnvironment discretionary discretionary budget authority for ATDSRappropriations for ATSDR, ,
 $903 million in  $903 million in mandatory PPHF appropriations,  $151 million inPPHF 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,

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), H2860-
H2862.
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-CDC-
congressional-justification.pdf, p. 10.
36 CDC, Congressional Budget Justification: FY2023 PHS evaluation tap transfers, and  $28 billion in proposed new mandatory public health preparedness funding, available over five years. This requested FY2023 core public health program level, including the new mandatory public health preparedness funding, would have represented a $30.277 billion (+356.9%) increase over the FY2022 enacted program level. Of the total increase, 92.5% of the amount would have been from the new proposed mandatory pandemic preparedness appropriation of $28 billion to be made available for five years.36 Excluding the pandemic preparedness funding, the proposed core public health program level would have been $10.675 billion, which would have represented a $2.273 billion (+27.1%) increase over the FY2022 enacted program level. In addition to the pandemic preparedness funding the request also proposed the following:  Consolidating 13 CDC LHHS accounts under a single appropriations heading, CDC-Wide Activities and Program Support.37  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.  VFC program modifications. CDC proposed 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 have also changed 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 FY2023 budget request, the FY2023 VFC funding estimate based on current law was $5.609 billion.38 35 CDC, Congressional Budget Justification: FY2023, https://www.cdc.gov/budget/documents/fy2023/FY-2023-CDC-congressional-justification.pdf. 36 This sections cites FY2023 enacted numbers from CDC, “FY2024 Budget Detail Table,” https://www.cdc.gov/budget/documents/fy2024/FY-2024-CDC-Budget-Detail.pdf. Numbers in the table account for some post-appropriations adjustments, specifically to account for some funding initially appropriated to the Public Health and Social Services Emergency Fund account for activities implemented by CDC (see footnote 8 of budget detail table). 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 CDC, FY2023 Budget Detail Table, https://www.cdc.gov/budget/documents/fy2023/FY-2023-CDC-Budget-, https://www.cdc.gov/budget/documents/fy2023/FY-2023-CDC-
congressional-justification.pdf.
Congressional Research Service Congressional Research Service

10

---

link to page 15 11 Centers for Disease Control and Prevention (CDC) Funding Overview

 $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.
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)FY2023 Enacted In December 2022, Congress and the President enacted the Consolidated Appropriations Act, 2023 (P.L. 117-328), which provided FY2023 LHHS appropriations in Division H and Interior/Environment appropriations in Division G. CDC’s FY2023 total core public health program level is $9.269 billion, comprising the following:39  $8.281 billion in LHHS discretionary appropriations for CDC,  $85 million in Interior/Environment discretionary appropriations for ATSDR, and  $903 million in mandatory PPHF appropriations. The FY2023 CDC core public health program level represents a $787 million increase (+9.3%) over the FY2022 CDC core public health program level. Relative to the FY2023 budget request, the enacted core public health program level is $29.491 billion less (-76.1%). However, of this difference, $28 billion is due to the proposed but not adopted mandatory pandemic preparedness proposal. Excluding the . Excluding the
proposed pandemic preparedness pandemic preparedness funding, the proposed core appropriations, the enacted core CDC public health program level 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
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

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.
Congressional Research Service

11

---

link to page 15 link to page 15 link to page 15 link to page 17 Centers for Disease Control and Prevention (CDC) Funding Overview

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 was $1.49 billion (-13.9%) less than the proposed level. All CDC discretionary appropriations accounts received nominal appropriations increases relative to FY2022 enacted levels. The accounts with the greatest relative increases were (1) CDC-Wide Activities (+46.6%), (2) Birth Defects, Developmental Disabilities, Disability and Health (+16.1%), and (3) Public Health Scientific Services (+15.7%). In addition to the proposed pandemic preparedness funding, the Administration’s other proposals were not adopted, including changes to the appropriations account structure, the mandatory Vaccines for Adults program, and VFC program modifications. FY2024 Request President Biden’s FY2024 budget request for CDC proposes a core public health program level of $11.667 billion, made up of the following:40  $10.217 billion in LHHS discretionary appropriations for CDC,  $86 million in Interior/Environment discretionary appropriations for ATSDR,  $1.186 billion in mandatory PPHF appropriations, and  $177 million in PHS evaluation tap transfers. Similar to President Biden’s FY2023 budget request, the CDC budget request proposes a new mandatory public health preparedness fund. For FY2024, President Biden’s budget proposes $6.1 billion in public health preparedness funding as a transfer to CDC from $20 billion total appropriated to the Public Health and Social Services Emergency Fund, to be available for five years. Unlike in the FY2023 proposal, the FY2024 proposed public health preparedness funding is presented as a non-add, and therefore not included within the FY2024 total program level for Detail.pdf. 39 This sections cites FY2023 enacted numbers from CDC, “FY2024 Budget Detail Table,” https://www.cdc.gov/budget/documents/fy2024/FY-2024-CDC-Budget-Detail.pdf. Numbers in the table account for some post-appropriations adjustments, specifically to account for $21.9 million initially appropriated to the Public Health and Social Services Emergency Fund account for activities implemented by CDC (see footnote 8 of budget detail table). 40 CDC, Congressional Budget Justification: FY2023, https://www.cdc.gov/budget/documents/fy2023/FY-2023-CDC-congressional-justification.pdf. Congressional Research Service 12 link to page 17 link to page 17 link to page 17 Centers for Disease Control and Prevention (CDC) Funding Overview CDC. The CDC core public health program level in addition to proposed new mandatory public health preparedness funding totals to $17.767 billion. Analysis of Proposed Pandemic Preparedness Mandatory Funding In both the FY2023 and FY2024 budget requests for CDC, the Biden Administration has proposed new five-year funding for pandemic preparedness:  FY2023 Request: $81.7 bil ion total for HHS, with $28 bil ion for CDC.  FY2024 Request: $20 bil ion total for HHS, with $6.1 bil ion for CDC. CRS fol ows the convention used in budget documents to analyze funding. In the FY2023 request budget documents, the proposed mandatory pandemic preparedness funds were shown as an “add,” or in other words, were included within CDC’s proposed FY2023 budget. The FY2024 budget displays the FY2024 pandemic preparedness funding as a non-add. CRS therefore fol ows that convention in Table 1, with some additional analysis to allow for comparisons between years. This requested FY2024 core public health program level would represent a $2.398 billion (+25.9%) increase over the FY2023 enacted program level. Including the proposed mandatory pandemic preparedness funding in the FY2024 requested total would represent a $8.498 billion (+91.7%) increase over the FY2023 enacted program level. Of the total increase to the core public health program level, 63.3% of the amount is composed of increases to five of the 17 program accounts. These accounts include Immunization and Respiratory Diseases; Chronic Disease Prevention and Health Promotion; Injury Prevention and Control; and Public Health Scientific Services. In addition to the pandemic preparedness funding the request also proposed the following:  Consolidating 13 CDC LHHS accounts under a single appropriations heading, CDC-Wide Activities and Program Support.41  Vaccines for Adults Program. According to the request, CDC submitted a legislative proposal for mandatory funding of $1.004 billion for a capped mandatory program to provide vaccines to adults.  VFC program modifications. Similar to the FY2023 request, the CDC proposes expanding eligibility for the VFC expanding eligibility for the VFC
program to all children under 19 years of age enrolled in the Children’s Health 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 Insurance Program (CHIP). The proposal would also change the fee structure for
providers participating in the program. The providers participating in the program. The FY2023FY2024 requested amount for VFC requested amount for VFC
iin Table 1 reflects the proposed program reflects the proposed program modifications.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 provides an overview of CDC/ATSDR budget and appropriations for FY2021 (final) 46FY2022 enacted
through the through the FY2023FY2024 budget request, reflecting all sources of regular budget authority (excludes budget request, reflecting all sources of regular budget authority (excludes
supplemental appropriations).supplemental appropriations).
Table 1. Centers for Disease Control and Prevention (CDC) and
Agency for Toxic Substances and Disease Registry (ATSDR) Appropriations, FY2021-
FY2023 Request
(Millions of Dollars)
2021
2022
2022
2023
Program or Activity
Final
Request
Enacted
Requesta
Immunization and Respiratory Diseases
820
946
868
1,251
PPHF Transfer (non-add)
(372)
(419)
(419)
(419)
HIV/AIDS, Viral Hepatitis, STI and TB
1,310
1,421
1,345
1,471

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-Budget-
Detail.pdf.
46 FY2021 final funding level reflects post-enactment transfers and other adjustments.
Congressional Research Service

12

---

link to page 17 link to page 17 link to page 17 link to page 17 Centers for Disease Control and Prevention (CDC) Funding Overview

2021
2022
2022
2023
Program or Activity
Final
Request
Enacted
Requesta
Emerging & Zoonotic Infectious Diseases
646
678
693
703 41 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; Occupational Safety and Health; Global Health; Public Health Preparedness and Response; and Cross-Cutting Activities and Program Support. CDC, FY2024 Budget Justification, p. 35, https://www.cdc.gov/budget/documents/fy2024/FY-2024-CDC-congressional-justification.pdf. Congressional Research Service 13 link to page 18 link to page 18 link to page 18 link to page 18 Centers for Disease Control and Prevention (CDC) Funding Overview Table 1. Centers for Disease Control and Prevention (CDC) and Agency for Toxic Substances and Disease Registry (ATSDR) Appropriations, FY2022- FY2024 Request (Millions of Dollars) 2022 2023 2023 FY2024 Program or Activity Final Requesta Enacted Request Immunization and Respiratory Diseases 868 1,251 919 1,256 PPHF Transfer (non-add) (419) (419) (419) (505) HIV/AIDS, Viral Hepatitis, STI and TB 1,345 1,471 1,391 1,545 Emerging & Zoonotic Infectious Diseases 693 703 751 846
PPHF Transfer (non-add)
(52)
(52)
(52)
(52)
Chronic Disease Prevention and Health Promotion
1,274339
1,453612
1,339430
1,612814
PPHF Transfer (non-add)
(255)
(255)
(255)
(255262)
Birth Defects, Developmental Disabilities, Disability
167177
173
177
195195 206 223
and Health
Environmental Health
222
333
228
402228 402 247 421
PPHF Transfer (non-add)
(17)
(17)
(17)
(17)
PHS Evaluation Transfer (non-add)
— —
(7)
— —
(7)
Vessel Sanitation (as appropriated in P.L. 117-43P.L. 117-43, Sec. 138b)
—(2)
— —
(2)—
— —
Injury Prevention and Control
681715
1,103
715
1,283283 761 1,352
Public Health Scientific Services
590652 799 754 962 PPHF Transfer (non-add) — — — (140)
742
652
799
PHS Evaluation Transfer (non-add)
— —
(132144)
— —
(144(170)
Occupational Safety and Health
344352
345
352
345363 363
Global Health
591
698
647
748647 748 693 765
Public Health Preparedness and Response
840Responsec 862
842
862
842905 943
Crosscutting Activities and Program Support
284
709
494
969494 969 724 1,039
PPHF Transfer (non-add)
(160)
(160)
(160)
(160210)
Office of the Director
(114)
(114124)
(114129)
(124144)
Infectious Diseases Rapid Response Reserve Fund
(1020)
(35)
(2035)
(35)
Public Health Infrastructure and Capacity
—
(400)
(200(200) (600) (350)
(600)
Center for Forecasting and Analytics
— —
—
—
(50(50) (50) (100)
Buildings and Facilities
30
55
3040
55
Pandemic Preparedness (proposed mandatory)
— —
—28,000
— —
28,000(6,100)
Agency for Toxic Substances and Disease Registry
7881
8285
8485
8586
(ATSDR)cd
Total, Core Public Health Program Level (CPHPL)
7,877
9,579
8,482
38,760
8,482 38,760 9,269 11,667 Total, CPHPL with FY2023 Proposed Mandatory 8,482 38,760 9,269 17,767 Pandemic Preparedness Less Pandemic Preparedness (proposed mandatory) Less Pandemic Preparedness (proposed mandatory)
— —
—-28,000
— —
-28,000 -6,100 Congressional Research Service 14 link to page 18 link to page 18 link to page 18 link to page 18 link to page 18 link to page 19 Centers for Disease Control and Prevention (CDC) Funding Overview 2022 2023 2023 FY2024 Program or Activity Final Requesta Enacted Request
Total, CPHPL without Pandemic Preparedness
7,877
9,579
8,482
10,6758,482 10,760 9,269 11,667
Less PPHF (mandatory) Less PPHF (mandatory)
- -856903
-903 -903
-903 -903
- -9031,186
Less PHS Evaluation Transfer Less PHS Evaluation Transfer
— —
139-151
— —
- -151177
Total, CDC/ATSDR Discretionary BA
7,020
8,676
7,578
9,706578 9,706 8,366 10,303
Less ATSDR Less ATSDR
- -7881
- -8285
- -8485
- -8586
Total, CDC LHHS Discretionary BA
6,942
8,455
7,499
9,621
Other Mandatory Programsd8,281 10,217
Vaccines for Children (VFC Vaccines for Children (VFC)
3,806)e
5,555540
5,555859
5,859
Congressional Research Service

13

---

link to page 17 link to page 17 link to page 18 Centers for Disease Control and Prevention (CDC) Funding Overview

2021
2022
2022
2023
Program or Activity
Final
Request
Enacted
Requesta609 6,002
Energy Employees Occupational Il ness Compensation Energy Employees Occupational Il ness Compensation
51
51
51
51
Program Act (EEOICPA Program Act (EEOICPA)ef
World Trade Center Health Program (WTCHP World Trade Center Health Program (WTCHP))g
551
641
641
710641 710 710 782
User Fees User Fees
2
2
2
2
Vaccines for Adults (proposed mandatory) Vaccines for Adults (proposed mandatory)
— —
—2,088
— — 1,004
2,088
Total Other Mandatory Programs
4,407
6,249
6,249
8,709Programsh 6,234 8,459 5,197 7,841
Total, Core Public Health Program Level + Other
12,286
15,828
14,732
47,46914,717 47,219 14,466 19,508
Mandatory
Source: FY2021 final amounts, FY2023 request amounts, and mandatory program amounts for all years are
from CDC, “FY2023FY2022 final, FY2023 enacted, and FY2024 requested amounts from CDC, “FY2024 Budget Detail Table,” https://www.cdc.gov/budget/documents/ Budget Detail Table,” https://www.cdc.gov/budget/documents/fy2023/FY-2023fy2024/FY-2024-CDC-congressional-justification.pdf. FY2023 requested discretionary appropriations -CDC-
Budget-Detail.pdf. FY2022 enacted discretionary appropriations and FY2022 request discretionary appropriations
are from are from Congressional Record, vol. 168, vol. 168, No. 42, (March 9, 2022), H2860-H2862no. 198 (December 20, 2022), S9142-S9144, and other mandatory program amounts from CDC, “FY2023 Budget Detail Table,” https://www.cdc.gov/budget/documents/fy2023/FY-2023-CDC-Budget-Detail.pdf, except where noted below. , except where noted below.
Notes: Individual amounts may not add to subtotals or totals due to rounding. 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 otherFY2022 final and FY2023 enacted amounts reflect some post-appropriations adjustments. Acronyms: HIV = Human Immunodeficiency adjustments. Acronyms: HIV = Human Immunodeficiency
Virus; AIDS = Acquired Immunodeficiency Syndrome; STI = Sexually Transmitted Infection; TB = Tuberculosis. Virus; AIDS = Acquired Immunodeficiency Syndrome; STI = Sexually Transmitted Infection; TB = Tuberculosis.
a. The FY2023 a. The FY2023 request proposesand FY2024 requests propose consolidating 13 CDC LHHS discretionary accounts into a single consolidating 13 CDC LHHS discretionary accounts into a single account. account.
b. The Extending Government Funding and Delivering Emergency Assistance Act (P.L. 117-43), one of the 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 mil ion for CDC’s vessel sanitation program. FY2022 continuing resolutions, provided an additional $1.5 mil ion for CDC’s vessel sanitation program.
c. c. This reflects $21 mil ion in appropriations from the Public Health and Social Services Emergency Fund for CDC activities added to the FY2023-appropriated amount ($883 mil ion). d. Provided separately in the Interior/Environment Provided separately in the Interior/Environment appropriations act. FY2022 enactedAppropriations Act. FY2023-requested amount from amount from
Congressional Record, vol. 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-Budget-
Detail.pdf.
d. FY2022 and FY2023 amounts are estimates for VFC. WTCHP, User Fees, and Vaccines for Adults.
e. Per the FY2023198, no. 11 (December 20, 2022), S8853. e. The FY2024 amount for VFC reflects proposed legislative changes. f. Per the FY2024 budget request table, all amounts for EEOICPA reflect sequestration and therefore differ budget request table, all amounts for EEOICPA reflect sequestration and therefore differ
from appropriated funding levels.
from appropriated funding levels. g. WTHCP amount does not include the $1 bil ion supplemental appropriation provided in Consolidated Appropriations Act, 2023 (P.L. 117-328). h. FY2023 and FY2024 amounts are estimates for VFC, WTCHP, User Fees, and Vaccines for Adults. Trends in Core Public Health Program Level
As shown iAs shown in Figure 6, from FY2011 to from FY2011 to FY2023FY2021, CDC’s core public health program level , CDC’s core public health program level has
remained mostly between $6.5 and $8 billion until the remained mostly between $6.5 and $8 billion until the increaseincreases provided in FY2022 ( provided in FY2022 (+9.0%) and FY2023 (+9.1%; not adjusted not adjusted
for inflation). From FY2011 to FY2021, CDC saw annual increases and decreases in its core for inflation). From FY2011 to FY2021, CDC saw annual increases and decreases in its core
public health funding level ranging from 1 to 6% (except for FY2013). public health funding level ranging from 1 to 6% (except for FY2013). For FY2013—the lowest
funding level in the period covered—budget sequestration of nonexempt discretionary spending
occurred.47

47 CDC, “Fact Sheet: Impact of Sequestration and other Budget Changes on the Centers for Disease Control and
Prevention,” https://www.cdc.gov/budget/documents/fy2013/fy-2013-sequester-impacts.pdf.
Congressional Research Service

14 Congressional Research Service 15

---

Centers for Disease Control and Prevention (CDC) Funding Overview
For FY2013—the lowest funding level in the period covered—budget sequestration of nonexempt discretionary spending occurred.42
Figure 6. Trends in Core Public Health Program Level
FY2011- FY2011-FY2023FY2024 Request

Source: CDC Congressional Budget Justifications, and sources in Table 1. CDC Congressional Budget Justifications, and sources in Table 1.
Congressional Research Service

15

---

Centers for Disease Control and Prevention (CDC) Funding Overview

Notes: FY2023PB* reflects Presidential Budget Request without the proposed Pandemic Preparedness funding;
FY2023PB** reflects Presidential Budget Request with the proposed Pandemic PreparednessNotes: Amounts are not adjusted for inflation. *President’s budget request; does not reflect proposed mandatory preparedness funding. Acronyms: funding. Acronyms:
CDC = Centers for Disease Control and Prevention; LHHS = Labor, Health and Human Services, Education, and CDC = Centers for Disease Control and Prevention; LHHS = Labor, Health and Human Services, Education, and
Related Agencies appropriations bil ; ATSDR = Agency for Toxic Substances and Disease Registry; PPHF = Related Agencies appropriations bil ; ATSDR = Agency for Toxic Substances and Disease Registry; PPHF =
Prevention and Public Health Fund; PHSSEF = Public Health and Social Services Emergency Fund; PHS = Public Prevention and Public Health Fund; PHSSEF = Public Health and Social Services Emergency Fund; PHS = Public
Health Service.Health Service.
CDC Budget in Context
Supplemental Appropriations for Public Health Emergencies and
Other Incidents
CDC regularly receives supplemental or one-time appropriations in response to public health CDC regularly receives supplemental or one-time appropriations in response to public health
emergencies and other incidents. For example, since 2019, CDC has received supplemental emergencies and other incidents. For example, since 2019, CDC has received supplemental
appropriations for hurricane and natural disaster response (for example, in P.L. 116-20appropriations for hurricane and natural disaster response (for example, in P.L. 116-20 and P.L. 42 CDC, “Fact Sheet: Impact of Sequestration and other Budget Changes on the Centers for Disease Control and Prevention,” https://www.cdc.gov/budget/documents/fy2013/fy-2013-sequester-impacts.pdf. Congressional Research Service 16 Centers for Disease Control and Prevention (CDC) Funding Overview 117-328), the ), the
Coronavirus Disease 2019 (COVID-19) pandemic,Coronavirus Disease 2019 (COVID-19) pandemic,4843 medical screening and supports for Afghan medical screening and supports for Afghan
refugees (P.L. 117-70), and for domestic and global activities related to the 2022 war in Ukraine refugees (P.L. 117-70), and for domestic and global activities related to the 2022 war in Ukraine
(P.L. 117-128). These amounts are not reflected in the other sections of this report as they are not (P.L. 117-128). These amounts are not reflected in the other sections of this report as they are not
intended to fund the regular operating expenses and programs of the agency. While these intended to fund the regular operating expenses and programs of the agency. While these
supplemental funds are, in most cases, primarily intended for the specific incident for which they supplemental funds are, in most cases, primarily intended for the specific incident for which they
are appropriated, they are sometimes correlated with cycles of funding increases and decreases are appropriated, they are sometimes correlated with cycles of funding increases and decreases
for overall public health capacity at the federal, state, and local levels. Large historical for overall public health capacity at the federal, state, and local levels. Large historical
supplemental appropriations to the agency and subsequent funding awards to state and local supplemental appropriations to the agency and subsequent funding awards to state and local
agencies includeagencies include:
  H1N1 influenza pandemic, 2009. In response to the H1N1 influenza pandemic, In response to the H1N1 influenza pandemic,
CDC received over $600 million and awarded $1.4 billion through its Public CDC received over $600 million and awarded $1.4 billion through its Public
Health Emergency Response Health Emergency Response (PHER) grantgrant program to state and local partners. to state and local partners.4944 These These
funds were made available to CDC from the Supplemental Appropriations Act of funds were made available to CDC from the Supplemental Appropriations Act of
2009 (P.L. 111-32), enacted in June 2009. 2009 (P.L. 111-32), enacted in June 2009.
  Ebola outbreak, 2014-2015. In response to the Ebola outbreak, Consolidated In response to the Ebola outbreak, Consolidated
and Further Continuing Appropriations Act, 2015 (P.L. 113-235; Division G), and Further Continuing Appropriations Act, 2015 (P.L. 113-235; Division G),
enacted in December 2014, provided CDC with $1.771 billion for both domestic enacted in December 2014, provided CDC with $1.771 billion for both domestic
and international Ebola preparedness and response efforts.and international Ebola preparedness and response efforts.5045 Using these funds, Using these funds,
CDC provided several supplemental grants to state and local agencies, including CDC provided several supplemental grants to state and local agencies, including
$145 million through the Public Health Emergency Preparedness (PHEP) $145 million through the Public Health Emergency Preparedness (PHEP)
cooperative agreement and over $114 million through the Epidemiology and cooperative agreement and over $114 million through the Epidemiology and
Laboratory Capacity (ELC) grant program.Laboratory Capacity (ELC) grant program.51

4846  Zika outbreak, 2016. The Zika Response and Preparedness Appropriations Act, 2016 (P.L. 114-223; Division B) provided $394 million to CDC in supplemental appropriations for preparedness and response to the Zika outbreak, domestically and internationally.47 CDC obligated a portion of the funding to state and local agencies through several grant programs, including over $184 million through the ELC grant program.48  COVID-19 pandemic, 2020-present. As reported by GAO, as of January 2023, CDC has received $26.4 billion through the COVID-19 relief appropriations measures to the CDC-Wide Activities and Program Support Account.49 Some of 43 See CRS Report R46711, See CRS Report R46711, U.S. Public Health Service: COVID-19 Supplemental Appropriations in the 116th
Congress and CRS Report R46834, and CRS Report R46834, American Rescue Plan Act of 2021 (P.L. 117-2): Public Health, Medical Supply
Chain, Health Services, and Related Provisions. .
4944 U.S. Government Accountability Office, U.S. Government Accountability Office, Influenza Pandemic: Lessons from the H1N1 Pandemic Should be
Incorporated into Future Planning, GAO-11-632, June 2011, pp. 7, 16, https://www.gao.gov/assets/gao-11-632.pdf. , GAO-11-632, June 2011, pp. 7, 16, https://www.gao.gov/assets/gao-11-632.pdf.
5045 P.L. 113-234, 128 Stat. 2520. P.L. 113-234, 128 Stat. 2520.
5146 CDC, “Ebola Funding,” https://www.cdc.gov/cpr/readiness/funding-ebola.htm, and data provided by CDC to CRS on CDC, “Ebola Funding,” https://www.cdc.gov/cpr/readiness/funding-ebola.htm, and data provided by CDC to CRS on
April 22, 2022. See also U.S. Government Accountability Office, April 22, 2022. See also U.S. Government Accountability Office, Infectious Disease Threats: Funding and
Performance of Key Preparedness and Capacity-Building Programs, May 2018, https://www.gao.gov/assets/gao-18-, May 2018, https://www.gao.gov/assets/gao-18-
362.pdf. 362.pdf.
Congressional Research Service

16

---

Centers for Disease Control and Prevention (CDC) Funding Overview

 Zika outbreak, 2016. The Zika Response and Preparedness Appropriations Act,
2016 (P.L. 114-123; Division B) provided $394 million to CDC in supplemental
appropriations preparedness and response to the Zika outbreak, domestically and
internationally.52 CDC obligated a portion of the funding to state and local
agencies through several grant programs, including over $184 million through
the ELC grant program.53
 COVID-19 pandemic, 2020-present. As reported by GAO, as of February 28,
2022, CDC has received $27.226 billion through the COVID-19 relief
appropriations measures.54 Some of the one-time public health funding in the
47 P.L. 114-223, 130 Stat. 901- 130 Stat. 902. 48 U.S. Government Accountability Office, Zika Supplement: Status of HHS Agencies’ Obligations, Disbursements, and the Activities Funded, GAO-18-389, May 2018, pp. 33-54, https://www.gao.gov/assets/gao-18-389.pdf, and data provided by CDC to CRS on April 22, 2022. 49 CDC received funding from five different COVID-19 relief laws: P.L. 116-123, P.L. 116-136, P.L. 116-139, P.L. 116-260, and P.L. 117-2. U.S. Government Accountability Office, COVID-19 Relief: Funding and Spending as of Jan. 31, 2023, GAO- 23-106647, February 2023, https://www.gao.gov/assets/gao-23-106647.pdf. Congressional Research Service 17 link to page 22 link to page 12 Centers for Disease Control and Prevention (CDC) Funding Overview the one-time public health funding for CDC in the American Rescue Plan Act (ARPA; P.L. 117-2) was not tied to the pandemic, but American Rescue Plan Act (ARPA; P.L. 117-2) was not tied to the pandemic, but
instead was made available for general public health capabilities, such as for data instead was made available for general public health capabilities, such as for data
modernization (Section 2404; $500 million). In addition, CDC has modernization (Section 2404; $500 million). In addition, CDC has received at least $1 billion in transfers and has administered administered
over $40 billion in appropriations on behalf of HHS through its grant programs over $40 billion in appropriations on behalf of HHS through its grant programs
(from the PHSSEF accountfrom the PHSSEF account).55.50 As a result, As a result, $56.119of the total appropriated to and administered by CDC, $59.481 billion in CDC COVID-19 billion in CDC COVID-19
grants have been awarded to state, tribal, and local agencies as of grants have been awarded to state, tribal, and local agencies as of February 1,
2022.56December 2022 (amount includes some regular appropriations).51 For more information on CDC funding in the COVID-19 relief laws, see, For more information on CDC funding in the COVID-19 relief laws, see,
CRS Report R46711, CRS Report R46711, U.S. Public Health Service: COVID-19 Supplemental
Appropriations in the 116th Congress and CRS Report R46834, and CRS Report R46834, American Rescue
Plan Act of 2021 (P.L. 117-2): Public Health, Medical Supply Chain, Health
Services, and Related Provisions.
Congress often appropriates emergency supplemental funding to HHS Congress often appropriates emergency supplemental funding to HHS on a flexible basisfor purposes that are somewhat general, or with the authority for HHS to transfer those funds, and , and
therefore HHS decides the final allocation of funds among HHS operating divisions (such as therefore HHS decides the final allocation of funds among HHS operating divisions (such as
CDC). Final data on HHS supplemental appropriations allocations are not available for all public CDC). Final data on HHS supplemental appropriations allocations are not available for all public
health emergencies listed above. health emergencies listed above.
CDC Infectious Diseases Rapid Response Reserve Fund
Through FY2019 appropriations (P.L. 115-245), Congress established an Infectious Diseases Through FY2019 appropriations (P.L. 115-245), Congress established an Infectious Diseases
Rapid Response Reserve Fund (IDRRRF) at CDC.Rapid Response Reserve Fund (IDRRRF) at CDC.5752 The IDRRRF is an emergency reserve fund The IDRRRF is an emergency reserve fund
available specifically for infectious disease emergencies. Funds may be drawn from IDRRRF for available specifically for infectious disease emergencies. Funds may be drawn from IDRRRF for
an infectious disease emergency if the HHS Secretaryan infectious disease emergency if the HHS Secretary:

52 P.L. 114-223, 130 Stat. 901- 130 Stat. 902.
53 U.S. Government Accountability Office, Zika Supplement: Status of HHS Agencies’ Obligations, Disbursements, and
the Activities Funded, GAO-18-389, May 2018, pp. 33-54, https://www.gao.gov/assets/gao-18-389.pdf, and data
provided by CDC to CRS on April 22, 2022.
54 CDC received funding from five different COVID-19 relief laws: P.L. 116-123, P.L. 116-136, P.L. 116-139, P.L.
116-260, and P.L. 117-2. These allocations include appropriations specifically directed to CDC in the laws and
appropriations allocated by the HHS Secretary to CDC. U.S. Government Accountability Office, COVID-19: Current
and Future Federal Preparedness Requires Fixes to Improve Health Data and Address Improper Payments, GAO-22-
105397, April 27, 2022, https://files.gao.gov/reports/GAO-22-105397/index.html#appendix4.
55  declares a public health emergency pursuant to PHSA Section 319, or  determines that the infectious disease emergency “has significant potential to imminently occur and potential, on occurrence, to affect national security or the health, and security of United States citizens, domestically or internationally.” The CDC Director may transfer IDRRRF funds to other CDC accounts as well as to National Institutes of Health (NIH) accounts or the PHSSEF account.53 Since FY2019, the IDRRRF has received the following regular and supplemental appropriations shown in Table 2. 50 CDC, “Budget: Novel Coronavirus (COVID-19),” https://www.cdc.gov/budget/fact-sheets/covid-19/index.html, CDC, “CDC in Action: Working 24/7 to Stop the Threat of COVID-19,” February 4, 2021, https://www.cdc.gov/CDC, “CDC in Action: Working 24/7 to Stop the Threat of COVID-19,” February 4, 2021, https://www.cdc.gov/
budget/documents/covid-19/CDC-247-Response-to-COVID-19-fact-sheet.pdf, and HHS, “Biden Administration to budget/documents/covid-19/CDC-247-Response-to-COVID-19-fact-sheet.pdf, and HHS, “Biden Administration to
Invest More Than $12 Billion to Expand COVID-19 Testing,” press release, March 17, 2021, https://www.hhs.gov/Invest More Than $12 Billion to Expand COVID-19 Testing,” press release, March 17, 2021, https://www.hhs.gov/
about/news/2021/03/17/biden-administration-invest-more-than-12-billion-expand-covid-19-testing.html. about/news/2021/03/17/biden-administration-invest-more-than-12-billion-expand-covid-19-testing.html.
5651 CDC, “CDC COVID-19 State, Tribal, Local, and Territorial Funding,” CDC, “CDC COVID-19 State, Tribal, Local, and Territorial Funding,” data last updated last updated February 1December 19, 2022, , 2022,
https://www.cdc.gov/budget/fact-sheets/covid-19/funding/index.html. https://www.cdc.gov/budget/fact-sheets/covid-19/funding/index.html.
5752 Department of Defense and Labor, Health and Human Services, and Education Appropriations Act, 2019 and Department of Defense and Labor, Health and Human Services, and Education Appropriations Act, 2019 and
Continuing Appropriations Act, 2019, P.L. 115-245, Division B, Title II, Section 231. Codified at 42 U.S.C. §247d-4a. Continuing Appropriations Act, 2019, P.L. 115-245, Division B, Title II, Section 231. Codified at 42 U.S.C. §247d-4a.
Congressional Research Service

17

---

link to page 21 link to page 11 Centers for Disease Control and Prevention (CDC) Funding Overview

 declares a public health emergency pursuant to PHSA Section 319, or
 determines that the infectious disease emergency “has significant potential to imminently
occur and potential, on occurrence, to affect national security or the health, and security
of United States citizens, domestically or internationally.”
The CDC Director may transfer IDRRRF funds to other CDC accounts as well as to National
Institutes of Health (NIH) accounts or the PHSSEF account.58
Since FY2019, the IDRRRF has received the following regular and supplemental appropriations
shown in Table 2.
Table 2. Appropriations History to the IDRRRF Account
Amount (dollars in
Fiscal Year
Law and Type of Appropriation
53 Per footnote 23, the PHSSEF account funds ASPR, the HHS lead operating division for medical and public health preparedness for, response to, and recovery from disaster and public health emergencies. ASPR oversees several programs, including the Biomedical Advanced Research and Development Authority and the Strategic National Stockpile. Congressional Research Service 18 Centers for Disease Control and Prevention (CDC) Funding Overview Table 2. Appropriations History to the IDRRRF Amount Fiscal Year Law and Type of Appropriation (dollars in millions)
FY2019 FY2019
P.L. 115-245, regular P.L. 115-245, regular
$50 $50
FY2020 FY2020
P.L. 116-94, regular P.L. 116-94, regular
$85 $85
P.L. 116-123, supplemental P.L. 116-123, supplemental
$300 $300
P.L. 116-136, supplemental P.L. 116-136, supplemental
$300 $300
FY2021 FY2021
P.L. 116-260 (Division H), regular P.L. 116-260 (Division H), regular
$10 $10
FY2022 FY2022
P.L. 117-103, regular P.L. 117-103, regular
$20 $20 FY2023 P.L. 117-328, (Division H), regular $35
Source: CRS analysis of appropriations laws. CRS analysis of appropriations laws.
IDRRRF funding has been used for multiple responses, including for recent Ebola outbreaks in IDRRRF funding has been used for multiple responses, including for recent Ebola outbreaks in
Africa and for the COVID-19 pandemic response.Africa and for the COVID-19 pandemic response.5954 As of As of July 29, 2022March 2, 2023, the IDRRRF has an , the IDRRRF has an
unobligated balance of $unobligated balance of $609.4600.6 million. million.6055
Other reserve fund accounts outside of CDC can also support public health emergency response. Other reserve fund accounts outside of CDC can also support public health emergency response.
These include the (1) Public Health Emergency Fund [PHSA These include the (1) Public Health Emergency Fund [PHSA Sec.Section 319(b), 42 319(b), 42 USC U.S.C. §247d(b)] and 247d(b)] and
(2) the Disaster Relief Fund at the Department of Homeland Security. (A detailed discussion of (2) the Disaster Relief Fund at the Department of Homeland Security. (A detailed discussion of
these funding sources is outside the scope of this report.) The Public Health Emergency Fund these funding sources is outside the scope of this report.) The Public Health Emergency Fund
currently has a balance of $56,currently has a balance of $56,000500 and has not received appropriations for many years. and has not received appropriations for many years.6156
Transfers from the Disaster Relief Fund have funded HHS’s response to non-infectious disease Transfers from the Disaster Relief Fund have funded HHS’s response to non-infectious disease
emergencies, such as for natural disasters, pursuant to authorities in the Robert T. Stafford emergencies, such as for natural disasters, pursuant to authorities in the Robert T. Stafford
Disaster Relief and Emergency Assistance Act (Stafford Act; 42 U.S.C. §§5721 et seq.). Stafford Disaster Relief and Emergency Assistance Act (Stafford Act; 42 U.S.C. §§5721 et seq.). Stafford
Act assistance was not available for HHS’s response to three recent infectious disease epidemics Act assistance was not available for HHS’s response to three recent infectious disease epidemics
prior to the Coronavirus Disease 2019 (COVID-19) pandemic—the H1N1 influenza pandemic in prior to the Coronavirus Disease 2019 (COVID-19) pandemic—the H1N1 influenza pandemic in

58 Per footnote 20, the PHSSEF account funds ASPR, the HHS lead office for medical and public health preparedness
for, response to, and recovery from disaster and public health emergencies. ASPR oversees several programs, including
the Biomedical Advanced Research and Development Authority and the Strategic National Stockpile.
592009, the Ebola virus outbreak in 2014, and the Zika virus outbreak in 2016.57 Congress subsequently established the IDRRRF in 2018. State and Local Funding for Public Health In the U.S. federal system, 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 (typically in the form of grants or cooperative agreements)—especially to state and local health departments. For example, in FY2019, 58% of CDC’s $5.652 billion in grants were awarded to government entities, the majority of which were state and local government recipients.58 As a 54 See “Response Funding” section of CRS Report R46219, See “Response Funding” section of CRS Report R46219, Overview of U.S. Domestic Response to Coronavirus
Disease 2019 (COVID-19). .
6055 USASpending.gov, “Infectious Diseases Rapid Response Reserve Fund, Centers for Disease Control, Health and USASpending.gov, “Infectious Diseases Rapid Response Reserve Fund, Centers for Disease Control, Health and
Human Services,” last updated Human Services,” last updated June 30, 2022March 2, 2023, https://www.usaspending.gov/federal_account/075-0945, https://www.usaspending.gov/federal_account/075-0945.
6156 USASpending.gov, “Public Health Emergency Fund, Public Health Services, Office of Assistant Secretary for USASpending.gov, “Public Health Emergency Fund, Public Health Services, Office of Assistant Secretary for
Health, Health and Human Services,” https://www.usaspending.gov/federal_account/075-1104. Health, Health and Human Services,” https://www.usaspending.gov/federal_account/075-1104.
Congressional Research Service

18

---

Centers for Disease Control and Prevention (CDC) Funding Overview

2009, the Ebola virus outbreak in 2014, and the Zika virus outbreak in 2016.62 Congress
subsequently established the IDRRRF in 2018.
State and Local Funding for Public Health
In the U.S. federal system, 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
(typically in the form of grants or cooperative agreements)—especially to state and local health
departments. For example, in FY2019, 58% of CDC’s $5.652 billion in grants were awarded to
government entities, the majority of which were state and local government recipients.63 As a
57 See CRS Insight IN11229, Stafford Act Assistance for Public Health Incidents. 58 CDC, “Office of Financial Resources: FY2019 Assistance Snapshot,” https://www.cdc.gov/funding/documents/fy2019/fy-2019-ofr-assistance-snapshot-508.pdf. FY2019 data are cited here instead of FY2020 and FY2021 data, as those years reflect significant amounts of COVID-19-specific grant funding that are not reflective of CDC’s usual grant practices. Congressional Research Service 19 link to page 24 Centers for Disease Control and Prevention (CDC) Funding Overview major source of funding, CDC budget trends influence state and local budgets for public health major source of funding, CDC budget trends influence state and local budgets for public health
initiatives. State and local health departments also receive federal funding from other agencies initiatives. State and local health departments also receive federal funding from other agencies
(e.g., Heath Services and Resources Administration), but CDC is a main source of funding for (e.g., Heath Services and Resources Administration), but CDC is a main source of funding for
core public health activities such as infectious disease control or chronic disease prevention. core public health activities such as infectious disease control or chronic disease prevention.
CDC’s funding awards complement state and local governments’ own funding for public health. CDC’s funding awards complement state and local governments’ own funding for public health.
CDC’s funding and its overall impact on U.S. public health capacity are perhaps best viewed in CDC’s funding and its overall impact on U.S. public health capacity are perhaps best viewed in
the context of state and local funding trends. the context of state and local funding trends.
Trends
There is no single source of standardized and generally accepted data on public health funding at There is no single source of standardized and generally accepted data on public health funding at
the federal, state, and local level, which hinders the federal, state, and local level, which hinders any analysis of public health funding trends.analysis of public health funding trends.6459
Analyses have found differing trends in state and local public health funding in recent years. Analyses have found differing trends in state and local public health funding in recent years.
Federal data in the National Health Expenditure (NHE) Accounts show that state and local Federal data in the National Health Expenditure (NHE) Accounts show that state and local
investments for public health grew from $73.5 billion in 2014 to $91.7 billion (+24.8%) by investments for public health grew from $73.5 billion in 2014 to $91.7 billion (+24.8%) by
2019.2019.6560
However, academic researchers (Leider, Resnick, and McCullough, 2020) have argued that the However, academic researchers (Leider, Resnick, and McCullough, 2020) have argued that the
NHE data overestimates actual spending on public health.NHE data overestimates actual spending on public health.6661 An analysis by Alfonso, Leider, and An analysis by Alfonso, Leider, and
Resnick (2021) used different methodology from NHE, and found that state government spending Resnick (2021) used different methodology from NHE, and found that state government spending
on public health had remained mostly flat or declined between 2008 and 2018 with some on public health had remained mostly flat or declined between 2008 and 2018 with some

62 See CRS Insight IN11229, Stafford Act Assistance for Public Health Incidents.
63 CDC, “Office of Financial Resources: FY2019 Assistance Snapshot,” https://www.cdc.gov/funding/documents/
fy2019/fy-2019-ofr-assistance-snapshot-508.pdf. FY2019 data are cited here instead of FY2020 and FY2021 data, as
those years reflect significant amounts of COVID-19-specific grant funding that are not reflective of CDC’s usual grant
practices.
64 Arthur L. Sensenig, Beth A. Resnick, and Jonathon P. Leider,variability across states.62 (State public health spending amounts in this analysis include federal grant funding to states, whereas the NHE state and local data do not.) Figure 7 shows per capita inflation-adjusted trends in state spending by public health category from the 2021 analysis. 59 Arthur L. Sensenig et al., “The Who, What, How, and Why of Estimating et al., “The Who, What, How, and Why of Estimating
Public Health Activity Spending,” Public Health Activity Spending,” Public Health Management and Practice, vol. 23, no. 6 (November/December , vol. 23, no. 6 (November/December
2017), pp. 556-559. 2017), pp. 556-559.
6560 Micah Hartman Micah Hartman, Anne B. Martin, and Benjamin Washington, et al., “National Health Care Spending In 2020: et al., “National Health Care Spending In 2020:
Growth Driven By Federal Spending In Response To The COVID-19 Pandemic,” Growth Driven By Federal Spending In Response To The COVID-19 Pandemic,” Health Affairs, vol. 1 (2022), pp. 13-, vol. 1 (2022), pp. 13-
25. 2020 data excluded because of the large one-time funding increases for public health during the COVID-19 25. 2020 data excluded because of the large one-time funding increases for public health during the COVID-19
pandemic. The National Health Expenditures Accounts classify multiple federal public health agency appropriations pandemic. The National Health Expenditures Accounts classify multiple federal public health agency appropriations
into the overall “public health activity” category, including CDC and the U.S. Food and Drug Administration. The state into the overall “public health activity” category, including CDC and the U.S. Food and Drug Administration. The state
and local funding is based on census data on state and local government budgets. Federal grant awards to state and and local funding is based on census data on state and local government budgets. Federal grant awards to state and
local governments are deducted to avoid double counting the federal funding in the state and local funding category. local governments are deducted to avoid double counting the federal funding in the state and local funding category.
See Centers for Medicare & Medicaid Services, See Centers for Medicare & Medicaid Services, National Health Expenditure Accounts: Methodology Paper, 2020, pp. , pp.
27-28, https://www.cms.gov/files/document/definitions-sources-and-methods.pdf. 27-28, https://www.cms.gov/files/document/definitions-sources-and-methods.pdf.
6661 Jonathan P. Leider Jonathan P. Leider, Beth Resnick, and Mac McCullough, et al., “Inaccuracy of Official Estimates of Public Health et al., “Inaccuracy of Official Estimates of Public Health
Spending in the United States, 2000–2018,” Spending in the United States, 2000–2018,” American Journal of Public Health, vol. 110 (April 4, 2020), pp. S194-vol. 110 (April 4, 2020), pp. S194-
S196.
Congressional Research Service

19

---

link to page 23
Centers for Disease Control and Prevention (CDC) Funding Overview

variability across states.67 (State public health spending amounts in this analysis include federal
funding to states, whereas the NHE state and local data do not.) Figure 7 shows per capita
inflation-adjusted trends in state spending by public health category from the 2021 analysis.S196. 62 Y. Natalia Alfonso et al., “US Public Health Neglected: Flat Or Declining Spending Left States Ill Equipped To Respond To COVID-19,” Health Affairs, vol. 40, no. 4 (March 25, 2021). Congressional Research Service 20 Centers for Disease Control and Prevention (CDC) Funding Overview
Figure 7. Inflation-adjusted Trends in State Spending on Public Health by Category
Per Capita from Alfonso, Leider, and Resnick, et al. (2021).


Source: Y. Natalia AlfonsoY. Natalia Alfonso, Jonathon P. Leider, and Beth Resnick, et al., “U.S. Public Health Neglected: Flat or et al., “U.S. Public Health Neglected: Flat or
Declining Spending Left States Il Equipped To Respond to COVID-19,” Declining Spending Left States Il Equipped To Respond to COVID-19,” Health Affairs, vol. 40, no. 4 (April 2021), , vol. 40, no. 4 (April 2021),
p. 667. p. 667.
Notes: Analysis used data from Census Bureau’s State Finance Division files as reported by state budget offices Analysis used data from Census Bureau’s State Finance Division files as reported by state budget offices
to the Census Bureau. The study authors re-coded the data to classify spending as public health spending. to the Census Bureau. The study authors re-coded the data to classify spending as public health spending.
Analysis does not include public health spending by local (county) governmentsAnalysis does not include public health spending by local (county) governments or federal spending on in-kind assistance to state governments (e.g., federal employee details). However, amounts do include . However, amounts do include
federal grants made to states as well as state funding that is ultimately transferred to local governments. federal grants made to states as well as state funding that is ultimately transferred to local governments.
Another source of data—the Association of State and Territorial Health Officials’ (ASTHO) Another source of data—the Association of State and Territorial Health Officials’ (ASTHO)
survey of state health departments—shows the following funding trends for specific categories survey of state health departments—shows the following funding trends for specific categories
relevant to pandemic preparedness:relevant to pandemic preparedness:6863
  For public health all-hazards preparedness and response activities, state state
funding for preparedness and response programs remained relatively constant funding for preparedness and response programs remained relatively constant
from 2010 to 2018 ($101 million to $112 million). However, federal funding to from 2010 to 2018 ($101 million to $112 million). However, federal funding to
states for preparedness and response declined approximately 48.5% from $1.440 states for preparedness and response declined approximately 48.5% from $1.440
billion in 2010 to $742 million in 2018. billion in 2010 to $742 million in 2018.
  For infectious disease prevention and control programs, state funding state funding
declined approximately 37.2% from $709 million in 2010 to $445 million in declined approximately 37.2% from $709 million in 2010 to $445 million in
2018. On the other hand, federal funding to states for infectious disease 2018. On the other hand, federal funding to states for infectious disease

67 Y. Natalia Alfonso, Jonathan P. Leider, and Beth Resnick, “US Public Health Neglected: Flat Or Declining Spending
Left States Ill Equipped To Respond To COVID-19,” Health Affairs, vol. 40, no. 4 (March 25, 2021).
68 Association of State and Territorial Health Officials (ASTHO), “State Health Agency Expenditures: 2010-2018,”
https://www.astho.org/globalassets/pdf/state-health-agency-expenditures-2010-2018.pdf.
Congressional Research Service

20

---

Centers for Disease Control and Prevention (CDC) Funding Overview

prevention and control activities declined approximately 10% from $1.095 billion prevention and control activities declined approximately 10% from $1.095 billion
in 2010 to $985 million in 2018. in 2010 to $985 million in 2018.
Local health departments receive funding from federal, state, and local sources. Local health Local health departments receive funding from federal, state, and local sources. Local health
departments have also reported flat or declining spending in recent years. According to a survey departments have also reported flat or declining spending in recent years. According to a survey
of local health departments by the National Association of County and City Health Officials of local health departments by the National Association of County and City Health Officials
(NACCHO), inflation-adjusted median per capita expenditures by local health departments (NACCHO), inflation-adjusted median per capita expenditures by local health departments
63 Association of State and Territorial Health Officials (ASTHO), “State Health Agency Expenditures: 2010-2018,” https://www.astho.org/globalassets/pdf/state-health-agency-expenditures-2010-2018.pdf. Congressional Research Service 21 Centers for Disease Control and Prevention (CDC) Funding Overview increased from $44 in 2008 to $50 in 2010, and then fell back to $41 by 2019.increased from $44 in 2008 to $50 in 2010, and then fell back to $41 by 2019.6964 Both ASTHO’s Both ASTHO’s
and NACCHO’s surveys rely on reported data from health departments, and therefore are subject and NACCHO’s surveys rely on reported data from health departments, and therefore are subject
to some limitations. to some limitations.
Other Funding-Related Challenges
Aside from overall trends, observers have cited other challenges in CDC public health funding Aside from overall trends, observers have cited other challenges in CDC public health funding
faced at the state and local level, includingfaced at the state and local level, including the following: :
  Variability. As noted earlier, supplemental appropriations for public health As noted earlier, supplemental appropriations for public health
emergencies can lead to periodic increases and decreases in overall public health emergencies can lead to periodic increases and decreases in overall public health
funding at the federal, state, and local levels. Some analysts have characterized funding at the federal, state, and local levels. Some analysts have characterized
emergency funding as contributing to “boom and bust” cycles where public emergency funding as contributing to “boom and bust” cycles where public
health capacity developed during an emergency is later lost due to subsequent health capacity developed during an emergency is later lost due to subsequent
funding decreases.funding decreases.7065 Some have also argued that reliance on the annual Some have also argued that reliance on the annual
appropriations process results in year-to-year funding variability that adversely appropriations process results in year-to-year funding variability that adversely
affects continuity of programs at the state and local level.affects continuity of programs at the state and local level.7166
  Siloed and categorical funding. As shown in this report, CDC has received As shown in this report, CDC has received
annual appropriations in recent years for disease or activity-specific categories. annual appropriations in recent years for disease or activity-specific categories.
These appropriations are then further designated for specific programs through These appropriations are then further designated for specific programs through
appropriations report language. States and other jurisdictions then receive appropriations report language. States and other jurisdictions then receive
categorical public health grants from these appropriations. Some analysts have categorical public health grants from these appropriations. Some analysts have
argued that siloed and categorical grants have hindered state and local public argued that siloed and categorical grants have hindered state and local public
health agencies’ ability to spend according to their priorities or emerging needs. health agencies’ ability to spend according to their priorities or emerging needs.
Analysts have also argued that state and local health agencies have not had Analysts have also argued that state and local health agencies have not had
sufficient flexibility to spend categorical grants on general capabilities, such as sufficient flexibility to spend categorical grants on general capabilities, such as
workforce and technology.workforce and technology.72
67  Competitive grant programs. In many cases, CDC does not receive enough funding for a specific program to award a grant to every state or local jurisdiction. In these cases, CDC awards the funding through a competitive
6964 National Association of County and City Health Officials (NACCHO), “2019 National Profile of Local Health National Association of County and City Health Officials (NACCHO), “2019 National Profile of Local Health
Departments,” p.69, https://www.naccho.org/uploads/downloadable-resources/Programs/Public-Health-Infrastructure/Departments,” p.69, https://www.naccho.org/uploads/downloadable-resources/Programs/Public-Health-Infrastructure/
NACCHO_2019_Profile_final.pdf. NACCHO_2019_Profile_final.pdf.
7065 Karen DeSalvo Karen DeSalvo, Bob Hughes, and Mary Bassett, et al., et al., Public Health COVID-19 Impact Assessment: Lessons
Learned and Compelling Needs, National Academy of Medicine, April 7, 2021, https://nam.edu/public-health-covid-, National Academy of Medicine, April 7, 2021, https://nam.edu/public-health-covid-
19-impact-assessment-lessons-learned-and-compelling-needs/, and Bipartisan Policy Center, 19-impact-assessment-lessons-learned-and-compelling-needs/, and Bipartisan Policy Center, Positioning America’s
Public Health System for the Next Pandemic, June 2021, p. 40, https://bipartisanpolicy.org/download/?file=/wp-, June 2021, p. 40, https://bipartisanpolicy.org/download/?file=/wp-
content/uploads/2021/06/Public-Health-Report_RV2.pdf, and Michelle R. Smith, Lauren Weber, and Hannah Recht, content/uploads/2021/06/Public-Health-Report_RV2.pdf, and Michelle R. Smith, Lauren Weber, and Hannah Recht,
“Public Health Experts Worry About Boom-Bust Cycle of Support,” “Public Health Experts Worry About Boom-Bust Cycle of Support,” Kaiser Health News, April 19, 2021, , April 19, 2021,
https://khn.org/news/article/public-health-experts-worry-about-boom-bust-cycle-of-support. https://khn.org/news/article/public-health-experts-worry-about-boom-bust-cycle-of-support.
7166 Institute of Medicine (now National Academy of Medicine), Institute of Medicine (now National Academy of Medicine), For the Public’s Health: Investing in a Healthier
Future, April 10, 2012, https://www.ncbi.nlm.nih.gov/books/NBK201023/. , April 10, 2012, https://www.ncbi.nlm.nih.gov/books/NBK201023/.
7267 Karen DeSalvo Karen DeSalvo, Bob Hughes, and Mary Bassett, et al., et al., Public Health COVID-19 Impact Assessment: Lessons
Learned and Compelling Needs, National Academy of Medicine, April 7, 2021, https://nam.edu/public-health-covid-, National Academy of Medicine, April 7, 2021, https://nam.edu/public-health-covid-
19-impact-assessment-lessons-learned-and-compelling-needs/, and Bipartisan Policy Center, 19-impact-assessment-lessons-learned-and-compelling-needs/, and Bipartisan Policy Center, Positioning America’s
Public Health System for the Next Pandemic, June 2021, pp. 38-39, https://bipartisanpolicy.org/download/?file=/wp-, June 2021, pp. 38-39, https://bipartisanpolicy.org/download/?file=/wp-
content/uploads/2021/06/Public-Health-Report_RV2.pdf, and Trust for America’s Health, content/uploads/2021/06/Public-Health-Report_RV2.pdf, and Trust for America’s Health, The Impact of Chronic
Congressional Research Service

21

---

Centers for Disease Control and Prevention (CDC) Funding Overview


Underfunding on America’s Public Health System, 2021, p., 2021, p. 11 https://www.tfah.org/wp-content/uploads/2021/05/11 https://www.tfah.org/wp-content/uploads/2021/05/
2021_PHFunding_Fnl.pdf. 2021_PHFunding_Fnl.pdf.
Congressional Research Service Congressional Research Service

22 22

---

Centers for Disease Control and Prevention (CDC) Funding Overview

 Competitive grant programs. In many cases, CDC does not receive enough
funding for a specific program to award a grant to every state or local
jurisdiction. In these cases, CDC awards the funding through a competitive
application process (consistent with federal requirements), unless the process for
awarding the funds is otherwise specified in law.73 Some observers have argued
application process (consistent with federal requirements), unless the process for awarding the funds is otherwise specified in law.68 Some observers have argued 68 See HHS, Grants Policy Statement, https://www.hhs.gov/sites/default/files/grants/grants/policies-regulations/hhsgps107.pdf. See also 45 C.F.R. Part 75. Congressional Research Service 23 Centers for Disease Control and Prevention (CDC) Funding Overview  that competitive funding disproportionately rewards agencies or organizations that competitive funding disproportionately rewards agencies or organizations
with the resources and skills to submit successful competitive grant applications. with the resources and skills to submit successful competitive grant applications.
The result is that agencies and organizations in poor or underserved communities The result is that agencies and organizations in poor or underserved communities
may be less likely to successfully obtain competitive grant funding.may be less likely to successfully obtain competitive grant funding.7469

Author Information

Kavya SekarKavya Sekar, Coordinator
Taylor R. Wyatt
Analyst in Health Policy
Analyst in Public Health Emergency Management


Hassan Z. Sheikh

Analyst in Public Health Emergency Management


Analyst in Health Policy Acknowledgments Former CRS Analyst in Public Health Emergency Management Taylor Wyatt and CRS Analyst in Health Policy Hassan Sheikh contributed to a previous version of this report. CRS Research Assistant John Gorman provided assistance for the update.
Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan
shared staff to congressional committees and Members of Congress. It operates solely at the behest of and shared staff to congressional committees and Members of Congress. It operates solely at the behest of and
under the direction of Congress. Information in a CRS Report should not be relied upon for purposes other under the direction of Congress. Information in a CRS Report should not be relied upon for purposes other
than public understanding of information that has been provided by CRS to Members of Congress in than public understanding of information that has been provided by CRS to Members of Congress in
connection with CRS’s institutional role. CRS Reports, as a work of the United States Government, are not connection with CRS’s institutional role. CRS Reports, as a work of the United States Government, are not
subject to copyright protection in the United States. Any CRS Report may be reproduced and distributed in subject to copyright protection in the United States. Any CRS Report may be reproduced and distributed in
its entirety without permission from CRS. However, as a CRS Report may include copyrighted images or its entirety without permission from CRS. However, as a CRS Report may include copyrighted images or
material from a third party, you may need to obtain the permission of the copyright holder if you wish to material from a third party, you may need to obtain the permission of the copyright holder if you wish to
copy or otherwise use copyrighted material. copy or otherwise use copyrighted material.


73 See HHS, Grants Policy Statement, https://www.hhs.gov/sites/default/files/grants/grants/policies-regulations/
hhsgps107.pdf. See also 45 C.F.R. Part 75.
7469 Institute of Medicine (now National Academy of Medicine), Institute of Medicine (now National Academy of Medicine), For the Public’s Health: Investing in a Healthier
Future, April 10, 2012, https://www.ncbi.nlm.nih.gov/books/NBK201015/, and Trust for America’s Health, , April 10, 2012, https://www.ncbi.nlm.nih.gov/books/NBK201015/, and Trust for America’s Health, The Impact
of Chronic Underfunding on America’s Public Health System, 2021, p., 2021, p. 11. https://www.tfah.org/wp-content/uploads/11. https://www.tfah.org/wp-content/uploads/
2021/05/2021_PHFunding_Fnl.pdf. 2021/05/2021_PHFunding_Fnl.pdf.
Congressional Research Service Congressional Research Service
R47207 R47207 · VERSION 1 · NEW
233 · UPDATED 24

---