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

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

CDC’s budget and appropriations with a focus on FY2022 enacted appropriations and the
FY2023 President’s budget request. The report also discusses supplemental appropriations for
Taylor R. Wyatt
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.
Emergency Management

This report divides CDC’s program level, 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:
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
programs. This is made up of discretionary and mandatory appropriations that are mostly provided or allocated
through the Departments of Labor, Health and Human Services, and Education, and Related Agencies (LHHS)
appropriations act, and
2. other mandatory programs that include several CDC-administered health services, compensation-related, and user
fee programs. These include the World Trade Center Health Program and user fees for cruise ship inspection, among
others.
CDC’s enacted FY2022 (P.L. 117-103) core public health program level is $8.482 billion, which represents a $606 million
(+7.7%) increase from the FY2021 final core public health program level, and is $1.1 billion (-11.5%) less than the
President’s FY2022 budget request. President Biden has proposed an FY2023 core public health program level of $38.76
billion, an increase of $30.277 billion (+356.9%) relative to the FY2022 enacted level. Of the total increase, 92.5% of the
amount is from a new proposed mandatory pandemic preparedness appropriation of $28 billion. Excluding the pandemic
preparedness funding, the proposed core public health program level is $10.675 billion, which would represent a $2.273
billion (+27.1%) increase over the FY2022 enacted program level.
From FY2011 to FY2021, CDC’s core public health funding level has remained between approximately $6.5 and $8 billion
until the increase provided in FY2022 (not adjusted for inflation). The lowest funding level of $6.28 billion in 2013 included
budget sequestration of nonexempt discretionary spending. CDC also frequently receives one-time supplemental
appropriations in response to specific incidents—such as infectious disease threats, natural disasters, or screening and health
support to refugees. In response to some incidents, such as the ongoing Coronavirus Disease 2019 (COVID-19) pandemic,
supplemental appropriations are substantial and are tied to short-term funding increases for overall public health capacity at
the federal, state, and local level. (These are not included in core public health funding as they are not intended to fund the
regular operating expenses and programs of the agency.)
In the United States, most public health activities are carried out by state and local governments. A large portion of CDC’s
annual budget is awarded as external financial assistance to state and local health departments (typically in the form of grants
or cooperative agreements). In addition to CDC funding, funding trends at the state and local level have a significant impact
on overall U.S. public health capacity. There is no source of standardized and generally accepted data on public health
funding at the federal, state, and local level, which hinders analysis of public health funding trends. However, several sources
indicate that public health funding at the state and local level has remained flat or declined over the past decade.
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Introduction
The Centers for Disease Control and Prevention (CDC), within the Department of Health and
Human Services (HHS), is a federal public health agency that develops and supports community-
based and population-wide programs and systems to promote health and to prevent the leading
causes of disease, injury, disability, and death, both domestically and globally. Its stated mission
is to “protect America from health, safety and security threats, both foreign and in the [United
States].”1 In addition to its role supporting ongoing public health activities, the agency has played
a major role in the federal response to the Coronavirus Disease 2019 (COVID-19) pandemic and
in other disease outbreaks and public health emergencies. The Agency for Toxic Substances and
Disease Registry (ATSDR), headed by the CDC director, is tasked with identifying potential
public health effects from exposure to hazardous substances.
Two features characterize CDC’s mission and programs. First, CDC programs tend to focus on
prevention of adverse health outcomes, rather than treatment or clinical care after a health issue
arises. Second, CDC programs focus on a population and community-wide health interventions,
rather than those that serve individuals. CDC also administers some health services and
compensation-related programs as discussed later in this report. CDC is organized into a number
of centers, institutes and offices (CIOs) as shown in Figure 1. Some of these CIOs focus on
specific public health challenges (e.g., injury prevention), while others focus on general public
health capabilities (e.g., surveillance and laboratory services).2
CDC as an agency is not explicitly established in authorizing law, though the agency is frequently
referenced in law—especially in provisions in the Public Health Service Act (PHSA). Many CDC
programs and activities are not explicitly authorized but are based in general and permanent
statutory authorities of the HHS Secretary, mostly in the PHSA.3 Four CDC CIOs4 and numerous
specific CDC programs5 are explicitly authorized. CDC also has certain regulatory
responsibilities.6
Given CDC’s mix of general and specific authorizations, appropriations play a central role in
guiding the agency’s policy priorities.

1 CDC, “Mission, Role, and Pledge,” https://www.cdc.gov/about/organization/mission.htm.
2 CDC, “Official Mission Statement & Organizational Chart,” https://www.cdc.gov/about/organization/cio-orgcharts/
index.html.
3 For example, PHSA Section 301 (42 U.S.C. §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
states for preventive health programs, and PHSA Section 319 (42 U.S.C. §247d) authorizes the Secretary to respond to
public health emergencies.
4 Explicitly authorized CDC components include the National Institute for Occupational Safety and Health (NIOSH),
authorized by the Occupational Safety and Health Act of 1970 (29 U.S.C. §§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
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,
Compensation and Liability Act of 1980 (CERCLA, the “Superfund” law; 42 U.S.C. §§9601 et seq.).
5 Among numerous others, PHSA Sections 317A et seq. authorize lead poisoning prevention activities, and PHSA Title
XXXIII authorizes the World Trade Center Health Program.
6 See CDC, “CDC Regulations,” https://www.cdc.gov/regulations/index.html.
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A large portion of CDC’s annual budget is awarded as external financial assistance (typically in
the form of grants or cooperative agreements)—especially to 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: HIV = Human Immunodeficiency Virus; STD = Sexually Transmitted Disease; TB = Tuberculosis.
Understanding CDC Appropriations
This CRS report divides CDC’s annual program level10 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.
10 For the purposes of this report, CDC’s program level is the sum of the agency’s funding for a fiscal year reflecting all
sources of budget authority.
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 core public health program level, funded mostly by annual discretionary
Departments of Labor, Health and Human Services, and Education, and Related
Agencies (LHHS) appropriations and mandatory Prevention and Public Health
Fund (PPHF) appropriations, and
 other mandatory programs, including health services or compensation-related
programs funded by program-specific mandatory budget authorities. In addition,
CDC receives funding from mandatory user fee programs.
CRS has divided CDC’s program level into the two categories to allow for valid year-to-year
comparisons of programmatic funding levels for the agency. The core public health program level
reflects both (1) funding for the main public health program activities conducted by CDC CIOs
and ATDSR in support of the agencies’ core missions, and (2) funding that is largely subject to
the annual appropriations process, and therefore reflects the legislative decisions made by
Congress each year to fund CDC and ATDSR programs. The CDC “core public health program
level” for FY2022 in this CRS report aligns with the “CDC/ATDSR program level” presented in
FY2023 CDC budget documents.11
The other mandatory programs excluded from the core public health program level have funding
levels that are mostly controlled by their program authorizations. The two largest programs—the
Vaccines for Children (VFC) program and the World Trade Health Center Program (WTHCP)—
primarily finance specific health services for eligible populations. Changes in annual funding
reflect usage and demand for the program services. These programs’ funding levels are therefore
presented separately from CDC’s core public health program level and are excluded from
analysis of funding trends for the agency’s main programmatic and operating expenses. These
other mandatory programs are also generally presented separately from the rest of CDC’s budget
in the agency’s own budget presentations.12

11 See CDC, “FY2023 Budget Detail Table,” https://www.cdc.gov/budget/documents/fy2023/FY-2023-CDC-Budget-
Detail.pdf. CDC changes its budget presentations and categories from year to year.
12 See, for example, CDC, “FY2023 Budget Detail Table,” https://www.cdc.gov/budget/documents/fy2023/FY-2023-
CDC-Budget-Detail.pdf.
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Figure 2. FY2022 Centers for Disease Control and Prevention Program Level by
Category and Budget Authority
Thousands of Dollars

Source: CDC, “FY2023 Budget Detail Table,” https://www.cdc.gov/budget/documents/fy2023/FY-2023-CDC-
Budget-Detail.pdf.
Notes: Acronyms: CDC = Centers for Disease Control and Prevention; WTCHP = World Trade Center
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 ;
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
CDCs CIOs. Types of funded activities include but are not limited to: developing expertise and
best practices in disease prevention and control; conducting and supporting public health
research; supporting and conducting public health surveillance and data collection; developing
public health laboratory capacity; supporting health education and promotion efforts;
coordinating and providing technical assistance to public health programs at the state and local
level; supporting some preventive health services programs (e.g., some vaccination and cancer
screening programs); and supporting public health emergency preparedness and response efforts.
Many of the programs support public health activities at the state and local level.13
CDC’s core public health program level is made up of (1) discretionary appropriations; (2),
mandatory appropriations from the Prevention and Public Health Fund (PPHF); and (3) some
other funding sources, such as transfers from other accounts.

13 See CDC, “Grant Funding Profiles,” https://fundingprofiles.cdc.gov/.
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Discretionary Appropriations. CDC receives funding through annual discretionary LHHS
appropriations, while ATSDR is separately funded by Interior/Environment appropriations.
Within LHHS appropriations, CDC receives funding in several accounts, many of which have
titles that align with the names of CDC CIOs. Some accounts fund activities through multiple
CIOs (e.g., Public Health Scientific Services). Some CDC accounts are for agency-wide
activities, such as the Buildings and Facilities account and the CDC-Wide Activities and Program
Support account.
As an example, the Injury Prevention and Control account funds activities at CDC’s National
Center for Injury Prevention and Control (NCIPC). The appropriations act text provides funding
to the Injury Prevention and Control account with respect to such activities as authorized by
several PHSA titles as shown in Figure 3.
Figure 3. Example of CDC Appropriation Language
From FY2021 LHHS Appropriations

Source: Consolidated Appropriations Act, 2021 (P.L. 116-260) Division H, Title II. 134 STAT. 1571.
Appropriations report language accompanying CDC appropriations generally specifies amounts
for programs or activities funded by CDC accounts in greater detail than the appropriations act
text. Shown below in Figure 4 is the FY2021 report language and funding table accompanying
the Injury Prevention and Control appropriation.14

14 For a general overview of appropriations report language, see CRS Report R44124, Appropriations Report
Language: Overview of Components and Development.
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Figure 4. Example of CDC Appropriations Report Language

Source: “Explanatory Statement Accompanying Consolidated Appropriations Act, 2021,” Congressional Record,
vol. 166 (December 21, 2020), p. H8623.
This CRS report focuses on account-level funding in Table 1. CDC’s annual Operating Plans
reflect programmatic funding levels within accounts as directed by appropriations report
language.15
Mandatory Appropriations from the Prevention and Public Health Fund (PPHF). In recent
years, some CDC LHHS accounts have received annual allocations of the mandatory PPHF
appropriations as directed in LHHS appropriations laws. The PPHF was established in 2010 in
Section 4002 the Affordable Care Act (ACA; P.L. 111-148, as amended) “to provide for expanded
and sustained national investment in prevention and public health programs to improve health and
help restrain the rate of growth in private and public sector health care costs.”16 The PPHF has its
own appropriation (provided by its authorizing law) and its own account within the HHS Office
of the Secretary. In recent years, appropriators have directed specific amounts of annual PPHF
funding to specific CDC accounts and programs (in addition to other HHS agencies) through
LHHS Appropriations Acts and accompanying report language.17 See Figure 5 for PPHF
allocations from FY2021 appropriations.

15 See CDC, Operating Plans, https://www.cdc.gov/budget/operating-plans/index.html.
16 42 U.S.C. § 300u-11(a).
17 Prior to FY2014, the HHS Secretary determined uses of the PPHF funding. See CRS Report R44796, The ACA
Prevention and Public Health Fund: In Brief, by Sarah A. Lister.
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Centers for Disease Control and Prevention (CDC) Funding Overview

Figure 5. Example of Prevention and Public Health Fund Allocations
From FY2021 LHHS Appropriations

Source: “Explanatory Statement Accompanying Consolidated Appropriations Act, 2021,” Congressional Record,
vol. 166 (December 21, 2020), p. H8634.
As shown in Figure 5, most of the FY2021 PPHF allocation went to CDC. Additional allocations
went to the Administration for Community Living (ACL) and the Substance Abuse and Mental
Health Services Administration (SAMHSA).
Other funding. CDC sometimes receives funding for its core public health program level
through transfers from other sources, including both discretionary and mandatory appropriations,
some subject to specific transfer rules.
Transfers. In some years, CDC has received transfers from other HHS accounts or appropriations
subject to specific transfer authorities. For example, as shown in Figure 6, CDC has received
occasional transfers from the Public Health and Social Services Emergency Fund (PHSSEF)18
and the Nonrecurring Expenses Fund (NEF) accounts.19 In some years, CDC also received LHHS
discretionary appropriations under the Public Health Service (PHS) Program Evaluation Set-
Aside, or the “PHS evaluation tap” transfer authority. Authorized by PHSA Section 241, the PHS
evaluation tap allows the HHS Secretary, with the approval of appropriators, to redistribute a
portion of eligible PHS agency appropriations across HHS for program evaluation purposes.
Recent LHHS Appropriations Acts have established the higher maximum percentage for the set-
aside and have distributed specific amounts of “Tap” funding to selected HHS programs. As
shown in Figure 6, CDC has not received PHS evaluation tap funding since FY2014. The PHS

18 The Public Health and Social Services Emergency Fund is an account of the HHS Secretary that funds several offices
and programs including the Administration for Strategic Preparedness and Response (ASPR), the HHS Cybersecurity
program, and the Office of National Security. It is also frequently used to provide emergency supplemental
appropriations for transfer by the HHS Secretary to agencies in HHS and elsewhere, according to legislative direction.
19 The NEF permits HHS to transfer unobligated balances of expired discretionary funds from FY2008 and subsequent
years into the NEF account. Statute authorizes use of the funds for capital acquisitions, including information
technology (IT) and facilities infrastructure (42 U.S.C. §3514a). Congress and the President can direct the funds to
certain accounts through appropriations acts.
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evaluation tap amounts shown in this CRS report reflect funds as appropriated, but do not reflect
final amounts of transfers out of CDC accounts under the same authority.
Smaller mandatory appropriations for public health programs. Some smaller CDC public health
programs have been funded by mandatory budget authorities, such as for the Childhood Obesity
Demonstration Project,20 as authorized in Social Security Act (SSA) Section 1139A(e)(8).21
Supplemental Appropriations
CDC has also received supplemental appropriations during public health emergencies and other specific incidents,
such as during the COVID-19 pandemic, as discussed further in “Supplemental Appropriations for Public Health
Emergencies.” Of note, the recently enacted COVID-19 supplemental appropriations and the American Rescue
Plan Act (P.L. 117-2) budget reconciliation measure included several major funding streams for general public
health capabilities not specific to the pandemic, such as for data modernization. These additional appropriations
are discussed in a separate section in this CRS report to distinguish regular appropriations for CDC’s annual
operations from these one-time appropriations.
Other Mandatory Programs
CDC also administers several health services and compensation programs that are funded by
mandatory budget authorities and are distinct from the agency’s core public health programs. In
several cases, annual funding levels for these programs are determined by the program’s
authorizing law. In addition, CDC receives a small amount of user fees through authorized user
fee programs.
The Vaccines for Children (VFC) program provides vaccines to enrolled health care providers
to vaccinate eligible children.22 As authorized in SSA Section 1928 (42 U.S.C. §1396s), the HHS
Secretary can purchase vaccines as necessary for eligible children at a federally negotiated
discounted price and then distribute vaccines to participating state and local health departments.
State and local health departments then distribute a portion of the supply to participating health
care providers and also administer vaccines through their own programs. In addition, some of the
annual VFC funding is awarded to states and other jurisdictions for program operations and
administration.23 VFC is financed by a Medicaid appropriation within the HHS Centers for
Medicare & Medicaid Services (CMS) and is administered by CDC.24 Like other Medicaid
programs, VFC is an appropriated entitlement, meaning that VFC funding is provided through
LHHS appropriations acts, but the funding level is determined based on budget projections for
meeting the funding needs of the program.25

20 Social Security Act (SSA) Section 1139(e)(8).
21 See, for example, funding for the CDC’s Childhood Obesity Research Demonstration (CORD) Project was initially
authorized through the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA; P.L. 111-3), and
$25 million was appropriated for FY2010 through FY2014 through the Affordable Care Act (ACA; P.L. 111-148, as
amended) in 2010. CDC, “Report to Congress on the Centers for Disease Control and Prevention’s Childhood Obesity
Research Demonstration Project,” https://www.cdc.gov/obesity/downloads/strategies/report-to-congress-CORD-
508.pdf.
22 VFC is funded by mandatory Medicaid appropriations that are transferred annually to CDC. See 42 U.S.C. § 1396s.
23 See “State Table: Vaccines for Children” in CDC, FY2022 Congressional Budget Justification, pp. 74-75,
https://www.cdc.gov/budget/documents/fy2022/FY-2022-CDC-congressional-justification.pdf.
24 Centers for Medicare & Medicaid Services (CMS), FY2023 Congressional Budget Justification, p. 107,
https://www.cms.gov/files/document/fy2023-cms-congressional-justification-estimates-appropriations-committees.pdf.
25 See CRS Report R42640, Medicaid Financing and Expenditures.
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The Energy Employees Occupational Illness Compensation Program (EEOICP) provides
compensation and medical benefits to eligible civilians (or their survivors) who have performed
duties related to the nuclear weapons production and testing programs of the Department of
Energy.26 CDC provides support to the program by conducting radiation dose estimates,
evaluating certain petitions, and providing other administrative support.27 Annual funding for
these CDC activities are generally provided pursuant to Section 151(b) of Division B, Title I of
Consolidated Appropriations Act, 2001 (P.L. 106-554), which specifies that annual funding
pursuant to that section shall be direct spending (i.e., mandatory appropriations).28
The World Trade Center Health Program (WTCHP) provides medical monitoring and
treatment to eligible individuals directly affected by the September 11, 2001 attacks for certain
incident-related health conditions. Furthermore, this program funds medical research into health
conditions that may develop due to exposure during the attacks.29 The program is authorized by
PHSA Title XXXIII (42 U.S.C. § 300mm et seq.) and funded through mandatory appropriations
in PHSA Section 3351 (42 USC §300mm–61).
User fee programs. CDC also receives relatively small amounts of user fees from authorized
user fee programs such as the vessel sanitation program30 and the respirator certification
program.31
FY2022 and FY2023 Budget and Appropriations
The following provides an overview of the budget and appropriations for CDC’s core public
health program level in fiscal years 2022 and 2023. Other CDC mandatory appropriations are not
addressed in the discussion as most are not subject to the annual appropriations process (except
for EEOICP), though estimates and amounts for those programs are summarized in Table 1.
However, some notable new mandatory programs proposed by the Biden Administration in
FY2023 are discussed below to explain the FY2023 total proposed program level.

26 CDC, “NIOSH Radiation Dose Reconstruction Program,” https://www.cdc.gov/niosh/ocas/faqsact.html.
27 CDC, “Energy Employees Occupational Illness Compensation Program Act (EEOICPA) Budget Request” in
FY2022 Congressional Budget Justification, p. 302, https://www.cdc.gov/budget/documents/fy2022/FY-2022-CDC-
congressional-justification.pdf.
28 See, for example, in FY2021 LHHS appropriations, 134 STAT 1571 of Division H, Title II, P.L. 116-260.
29 CDC, “World Trade Center Health Program,” https://www.cdc.gov/wtc/.
30 “The Vessel Sanitation Program (VSP) at the Centers for Disease Control and Prevention (CDC) assists the cruise
ship industry to prevent and control the introduction, transmission, and spread of gastrointestinal (GI) illnesses on
cruise ships.” Under authority in in PHSA Section 361; 42 U.S.C. § 264. See CDC, “Vessel Sanitation Program,”
https://www.cdc.gov/nceh/vsp/default.htm.
31 The respirator certification program conducts assessments and NIOSH approval of particulate filtering facepiece
respirators. 42 C.F.R. Part 84. See also CDC, Respirator Certification Fees Schedules,” https://www.cdc.gov/niosh/
npptl/respcertfeescheduletables.html.
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FY2022
President Biden submitted a summary of his FY2022 budget request for discretionary funding on
April 9, 2021,32 and subsequently released the full proposal on May 28, 2021. The request sought
$9.579 billion for CDC’s core public health program level, as follows:33
 $8.455 billion in LHHS discretionary budget authority for CDC,
 $82 million in Interior/Environmental discretionary budget authority for ATDSR,
 $903 million in PPHF funding, and
 $139 million under the PHS evaluation tap authority.
The requested FY2022 program level would have represented a $1.702 billion increase (+21.6%)
over CDC’s final FY2021 core public health program level of $7.877 billion. 34 As a significant
addition under the FY2022 request, $400 million in new funding would have been provided for
core public health infrastructure and capacity in the CDC-Wide Activities and Program Support
account. Per the budget request, the goal of the new funding was “to address critical gaps in
public health infrastructure and facilitate the transition from sporadic emergency funding to a
sustainable model that can respond to ongoing challenges and prevent future crises.”35
In March 2022, Congress and the President enacted the Consolidated Appropriations Act, 2022
(P.L. 117-103), which provided FY2022 LHHS appropriations in Division H and
Interior/Environment appropriations in Division G. The law provided CDC a total core public
health program level of $8.482 billion, comprising the following:
 $7.499 billion in LHHS discretionary appropriations for CDC,
 $81 million in Interior/Environment discretionary appropriations for ATSDR, and
 $903 million in mandatory PPHF appropriations.
The FY2022 enacted funding level represented a $606 million (+7.7%) increase from the FY2021
final core public health program level and was $1.1 billion (-11.5%) less than the President’s
FY2022 budget request. The requested new Public Health Infrastructure and Capacity
appropriation was funded at $200 million in the CDC-Wide Activities and Program Support
account—50% less than proposed in the request.
FY2023
President Biden’s FY2023 budget request for CDC proposes a core public health program level of
$38.76 billion made up of the following:36
 $9.621 billion in LHHS discretionary appropriations for CDC,

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, https://www.cdc.gov/budget/documents/fy2023/FY-2023-CDC-
congressional-justification.pdf.
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 $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). Excluding the
pandemic preparedness funding, the proposed core public health program level is $10.675 billion,
which would represent a $2.273 billion (+27.1%) increase over the FY2022 enacted program
level.
In addition, the request proposes a significant change in how annual discretionary funding is
appropriated to CDC. Specifically, the request proposes consolidating 13 CDC LHHS accounts
under a single appropriations heading, CDC-Wide Activities and Program Support.37 According
to the request, this consolidation would “enable the agency to more easily access all of its
resources to address a crisis” and mount a “whole of agency” response to a public health threat.38
This change would return CDC’s appropriations account structure to that of FY2010 and earlier
years when CDC received almost all of its discretionary appropriations under one heading.39
The budget request’s proposed LHHS discretionary appropriations legislative text would provide
the $9.621 billion total with a few set-asides specified in law, including $128.4 million for
international HIV/AIDS programs, $353.2 million for global health protection, $600 million for
public health infrastructure and capacity, and $50 million for forecasting epidemics and analytics
(all are existing programs).40 Separately, CDC has published a detailed budget table for FY2023
by programs, projects, and activities comparable to the current budget structure as shown in
Table 1. Per the request, CDC plans to continue to maintain accountability and transparency for
“the programs, projects and activities described in Congressional reports.”41
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.
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and other high consequence biological threats.”42 Per the request, the CDC appropriation would
support domestic and international public health surveillance and data monitoring activities;
medical countermeasure distribution networks; public health research, analytics, and forecasting;
public health laboratories; and other infrastructure and core capability investments such as for
emergency response structures, workforce, and data modernization.43
Other Legislative Proposals
CDC’s FY2023 budget request also includes several proposed mandatory programs or program
changes that would be authorized and likely controlled outside of the annual appropriations
process. The amounts shown in Table 1 reflect the following proposals:44
 Vaccines for Adults Program. According to the request, CDC submitted a
legislative proposal for mandatory funding of $25 billion provided over 10 years
to establish a new Vaccines for Adults program. The program would provide
Advisory Committee on Immunization Practices (ACIP)-recommended vaccines
to uninsured adults at no cost. Funded program activities would comprise vaccine
purchase, provider fees, and program operations.
 VFC program modifications. CDC proposes expanding eligibility for the VFC
program to all children under 19 years of age enrolled in the Children’s Health
Insurance Program (CHIP). The proposal would also change the fee structure for
providers participating in the program. The FY2023 requested amount for VFC
in Table 1 reflects the proposed program modifications. According to the budget
request, the FY2023 VFC funding estimate based on current law is $5.609
billion.45
Funding Table
Table 1 provides an overview of CDC/ATSDR budget and appropriations for FY2021 (final) 46
through the FY2023 budget request, reflecting all sources of regular budget authority (excludes
supplemental appropriations).
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.
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2021
2022
2022
2023
Program or Activity
Final
Request
Enacted
Requesta
Emerging & Zoonotic Infectious Diseases
646
678
693
703
PPHF Transfer (non-add)
(52)
(52)
(52)
(52)
Chronic Disease Prevention and Health Promotion
1,274
1,453
1,339
1,612
PPHF Transfer (non-add)
(255)
(255)
(255)
(255)
Birth Defects, Developmental Disabilities, Disability
167
173
177
195
and Health
Environmental Health
222
333
228
402
PPHF Transfer (non-add)
(17)
(17)
(17)
(17)
PHS Evaluation Transfer (non-add)
—
(7)
—
(7)
Vessel Sanitation (as appropriated in P.L. 117-43, Sec. 138b)
—
—
(2)
—
Injury Prevention and Control
681
1,103
715
1,283
Public Health Scientific Services
590
742
652
799
PHS Evaluation Transfer (non-add)
—
(132)
—
(144)
Occupational Safety and Health
344
345
352
345
Global Health
591
698
647
748
Public Health Preparedness and Response
840
842
862
842
Crosscutting Activities and Program Support
284
709
494
969
PPHF Transfer (non-add)
(160)
(160)
(160)
(160)
Office of the Director
(114)
(114)
(114)
(124)
Infectious Diseases Rapid Response Reserve Fund
(10)
(35)
(20)
(35)
Public Health Infrastructure and Capacity
—
(400)
(200)
(600)
Center for Forecasting and Analytics
—
—
—
(50)
Buildings and Facilities
30
55
30
55
Pandemic Preparedness (proposed mandatory)
—
—
—
28,000
Agency for Toxic Substances and Disease Registry
78
82
84
85
(ATSDR)c
Total, Core Public Health Program Level (CPHPL)
7,877
9,579
8,482
38,760
Less Pandemic Preparedness (proposed mandatory)
—
—
—
-28,000
Total, CPHPL without Pandemic Preparedness
7,877
9,579
8,482
10,675
Less PPHF (mandatory)
-856
-903
-903
-903
Less PHS Evaluation Transfer
—
139
—
-151
Total, CDC/ATSDR Discretionary BA
7,020
8,676
7,578
9,706
Less ATSDR
-78
-82
-84
-85
Total, CDC LHHS Discretionary BA
6,942
8,455
7,499
9,621
Other Mandatory Programsd
Vaccines for Children (VFC)
3,806
5,555
5,555
5,859
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2021
2022
2022
2023
Program or Activity
Final
Request
Enacted
Requesta
Energy Employees Occupational Il ness Compensation
51
51
51
51
Program Act (EEOICPA)e
World Trade Center Health Program (WTCHP)
551
641
641
710
User Fees
2
2
2
2
Vaccines for Adults (proposed mandatory)
—
—
—
2,088
Total Other Mandatory Programs
4,407
6,249
6,249
8,709
Total, Core Public Health Program Level + Other
12,286
15,828
14,732
47,469
Mandatory
Source: FY2021 final amounts, FY2023 request amounts, and mandatory program amounts for all years are
from CDC, “FY2023 Budget Detail Table,” https://www.cdc.gov/budget/documents/fy2023/FY-2023-CDC-
Budget-Detail.pdf. FY2022 enacted discretionary appropriations and FY2022 request discretionary appropriations
are from Congressional Record, vol. 168, No. 42, (March 9, 2022), H2860-H2862, except where noted below.
Notes: Individual amounts may not add to subtotals or totals due to rounding. Final amounts for FY2021 differ
from enacted funding levels due to transfers and other adjustments. Acronyms: HIV = Human Immunodeficiency
Virus; AIDS = Acquired Immunodeficiency Syndrome; STI = Sexually Transmitted Infection; TB = Tuberculosis.
a. The FY2023 request proposes consolidating 13 CDC LHHS discretionary accounts into a single account.
b. The Extending Government Funding and Delivering Emergency Assistance Act (P.L. 117-43), one of the
FY2022 continuing resolutions, provided an additional $1.5 mil ion for CDC’s vessel sanitation program.
c. Provided separately in the Interior/Environment appropriations act. FY2022 enacted amount from
Congressional Record, vol. 168, No. 42, (March 9, 2022), H2496. FY2022 request amount from CDC,
“FY2022 Budget Detail Table,” https://www.cdc.gov/budget/documents/fy2022/FY-2022-CDC-Budget-
Detail.pdf.
d. FY2022 and FY2023 amounts are estimates for VFC. WTCHP, User Fees, and Vaccines for Adults.
e. Per the FY2023 budget request table, all amounts for EEOICPA reflect sequestration and therefore differ
from appropriated funding levels.
Trends in Core Public Health Program Level
As shown in Figure 6 from FY2011 to FY2023, CDC’s core public health program level has
remained mostly between $6.5 and $8 billion until the increase provided in FY2022 (not adjusted
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). 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.
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Figure 6. Trends in Core Public Health Program Level
FY2011-FY2023

Source: CDC Congressional Budget Justifications, and sources in Table 1.
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Notes: FY2023PB* reflects Presidential Budget Request without the proposed Pandemic Preparedness funding;
FY2023PB** reflects Presidential Budget Request with the proposed Pandemic Preparedness funding. Acronyms:
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 =
Prevention and Public Health Fund; PHSSEF = Public Health and Social Services Emergency Fund; PHS = Public
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
emergencies and other incidents. For example, since 2019, CDC has received supplemental
appropriations for hurricane and natural disaster response (for example, in P.L. 116-20), the
Coronavirus Disease 2019 (COVID-19) pandemic,48 medical screening and supports for Afghan
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
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
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
supplemental appropriations to the agency and subsequent funding awards to state and local
agencies include:
 H1N1 influenza pandemic, 2009. In response to the H1N1 influenza pandemic,
CDC received over $600 million and awarded $1.4 billion through its Public
Health Emergency Response (PHER) grant to state and local partners.49 These
funds were made available to CDC from the Supplemental Appropriations Act of
2009 (P.L. 111-32), enacted in June 2009.
 Ebola outbreak, 2014-2015. In response to the Ebola outbreak, Consolidated
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
and international Ebola preparedness and response efforts.50 Using these funds,
CDC provided several supplemental grants to state and local agencies, including
$145 million through the Public Health Emergency Preparedness (PHEP)
cooperative agreement and over $114 million through the Epidemiology and
Laboratory Capacity (ELC) grant program.51

48 See CRS Report R46711, U.S. Public Health Service: COVID-19 Supplemental Appropriations in the 116th
Congress and CRS Report R46834, American Rescue Plan Act of 2021 (P.L. 117-2): Public Health, Medical Supply
Chain, Health Services, and Related Provisions.
49 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.
50 P.L. 113-234, 128 Stat. 2520.
51 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, Infectious Disease Threats: Funding and
Performance of Key Preparedness and Capacity-Building Programs, May 2018, https://www.gao.gov/assets/gao-18-
362.pdf.
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 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
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
modernization (Section 2404; $500 million). In addition, CDC has administered
over $40 billion in appropriations on behalf of HHS through its grant programs
(from the PHSSEF account).55 As a result, $56.119 billion in CDC COVID-19
grants have been awarded to state, tribal, and local agencies as of February 1,
2022.56 For more information on CDC funding in the COVID-19 relief laws, see,
CRS Report R46711, U.S. Public Health Service: COVID-19 Supplemental
Appropriations in the 116th Congress 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 on a flexible basis, and
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
health emergencies listed above.
CDC Infectious Diseases Rapid Response Reserve Fund
Through FY2019 appropriations (P.L. 115-245), Congress established an Infectious Diseases
Rapid Response Reserve Fund (IDRRRF) at CDC.57 The IDRRRF is an emergency reserve fund
available specifically for infectious disease emergencies. Funds may be drawn from IDRRRF for
an 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 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
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.
56 CDC, “CDC COVID-19 State, Tribal, Local, and Territorial Funding,” last updated February 1, 2022,
https://www.cdc.gov/budget/fact-sheets/covid-19/funding/index.html.
57 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.
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 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
millions)
FY2019
P.L. 115-245, regular
$50
FY2020
P.L. 116-94, regular
$85
P.L. 116-123, supplemental
$300
P.L. 116-136, supplemental
$300
FY2021
P.L. 116-260 (Division H), regular
$10
FY2022
P.L. 117-103, regular
$20
Source: CRS analysis of appropriations laws.
IDRRRF funding has been used for multiple responses, including for recent Ebola outbreaks in
Africa and for the COVID-19 pandemic response.59 As of July 29, 2022, the IDRRRF has an
unobligated balance of $609.4 million.60
Other reserve fund accounts outside of CDC can also support public health emergency response.
These include the (1) Public Health Emergency Fund [PHSA Sec. 319(b), 42 USC 247d(b)] and
(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
currently has a balance of $56,000 and has not received appropriations for many years.61
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
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
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.
59 See “Response Funding” section of CRS Report R46219, Overview of U.S. Domestic Response to Coronavirus
Disease 2019 (COVID-19).
60 USASpending.gov, “Infectious Diseases Rapid Response Reserve Fund, Centers for Disease Control, Health and
Human Services,” last updated June 30, 2022, https://www.usaspending.gov/federal_account/075-0945.
61 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.
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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
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
(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.
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
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
the federal, state, and local level, which hinders any analysis of public health funding trends.64
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
investments for public health grew from $73.5 billion in 2014 to $91.7 billion (+24.8%) by
2019.65
However, academic researchers (Leider, Resnick, and McCullough, 2020) have argued that the
NHE data overestimates actual spending on public health.66 An analysis by Alfonso, Leider, and
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

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, et al., “The Who, What, How, and Why of Estimating
Public Health Activity Spending,” Public Health Management and Practice, vol. 23, no. 6 (November/December
2017), pp. 556-559.
65 Micah Hartman, Anne B. Martin, and Benjamin Washington, et al., “National Health Care Spending In 2020:
Growth Driven By Federal Spending In Response To The COVID-19 Pandemic,” Health Affairs, vol. 1 (2022), pp. 13-
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
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
local governments are deducted to avoid double counting the federal funding in the state and local funding category.
See Centers for Medicare & Medicaid Services, National Health Expenditure Accounts: Methodology Paper, 2020, pp.
27-28, https://www.cms.gov/files/document/definitions-sources-and-methods.pdf.
66 Jonathan P. Leider, Beth Resnick, and Mac McCullough, et al., “Inaccuracy of Official Estimates of Public Health
Spending in the United States, 2000–2018,” American Journal of Public Health, vol. 110 (April 4, 2020), pp. S194-
S196.
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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.
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 Alfonso, Jonathon P. Leider, and Beth Resnick, et al., “U.S. Public Health Neglected: Flat or
Declining Spending Left States Il Equipped To Respond to COVID-19,” Health Affairs, vol. 40, no. 4 (April 2021),
p. 667.
Notes: 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.
Analysis does not include public health spending by local (county) governments. However, amounts do include
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)
survey of state health departments—shows the following funding trends for specific categories
relevant to pandemic preparedness:68
 For public health all-hazards preparedness and response activities, state
funding for preparedness and response programs remained relatively constant
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
billion in 2010 to $742 million in 2018.
 For infectious disease prevention and control programs, state funding
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

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.
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prevention and control activities declined approximately 10% from $1.095 billion
in 2010 to $985 million in 2018.
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
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
increased from $44 in 2008 to $50 in 2010, and then fell back to $41 by 2019.69 Both ASTHO’s
and NACCHO’s surveys rely on reported data from health departments, and therefore are subject
to some limitations.
Other Funding-Related Challenges
Aside from overall trends, observers have cited other challenges in CDC public health funding
faced at the state and local level, including:
 Variability. As noted earlier, supplemental appropriations for 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
emergency funding as contributing to “boom and bust” cycles where public
health capacity developed during an emergency is later lost due to subsequent
funding decreases.70 Some have also argued that reliance on the annual
appropriations process results in year-to-year funding variability that adversely
affects continuity of programs at the state and local level.71
 Siloed and categorical funding. As shown in this report, CDC has received
annual appropriations in recent years for disease or activity-specific categories.
These appropriations are then further designated for specific programs through
appropriations report language. States and other jurisdictions then receive
categorical public health grants from these appropriations. Some analysts have
argued that siloed and categorical grants have hindered state and local public
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
sufficient flexibility to spend categorical grants on general capabilities, such as
workforce and technology.72

69 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/
NACCHO_2019_Profile_final.pdf.
70 Karen DeSalvo, Bob Hughes, and Mary Bassett, 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-
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-
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,” Kaiser Health News, April 19, 2021,
https://khn.org/news/article/public-health-experts-worry-about-boom-bust-cycle-of-support.
71 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/.
72 Karen DeSalvo, Bob Hughes, and Mary Bassett, 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-
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-
content/uploads/2021/06/Public-Health-Report_RV2.pdf, and Trust for America’s Health, The Impact of Chronic
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Centers for Disease Control and Prevention (CDC) Funding Overview

Underfunding on America’s Public Health System, 2021, p.11 https://www.tfah.org/wp-content/uploads/2021/05/
2021_PHFunding_Fnl.pdf.
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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
that competitive funding disproportionately rewards agencies or organizations
with the resources and skills to submit successful competitive grant applications.
The result is that agencies and organizations in poor or underserved communities
may be less likely to successfully obtain competitive grant funding.74

Author Information

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

Hassan Z. Sheikh

Analyst in Public Health Emergency Management

Disclaimer
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
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
connection with CRS’s institutional role. CRS Reports, as a work of the United States Government, are not
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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
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.
74 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, The Impact
of Chronic Underfunding on America’s Public Health System, 2021, p.11. https://www.tfah.org/wp-content/uploads/
2021/05/2021_PHFunding_Fnl.pdf.
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