Public Health Funding and the Fiscal Responsibility Act of 2023

Public Health Funding and the Fiscal Responsibility Act of 2023

INSIGHTi

Public Health Funding and the Fiscal
Responsibility Act of 2023
July 31, 2023
The Fiscal Responsibility Act of 2023 (FRA; P.L. 118-5) affects federal public health agencies—
specifically the nine operating divisions that make up the U.S. Public Health Service (PHS) within the
Department of Health and Human Services (HHS)—in two key ways. First, the law rescinds certain
appropriations made available to these agencies under the six Coronavirus Disease 2019 (COVID-19)
relief laws. Second, the law introduces new discretionary spending limits for two years that may affect the
amount of PHS appropriations that are made available through regular appropriations.
The PHS includes some key agencies responsible for preparedness and response to public health
emergencies, such as the Administration for Strategic Preparedness and Response (ASPR) and the Centers
for the Disease Control and Prevention (CDC). PHS agencies also have significant roles in health
research, as such as the National Institutes of Health (NIH). The U.S. Food and Drug Administration
(FDA), a PHS component, protects health through regulating products such as drugs, foods, and
cosmetics, among others. Several PHS agencies support health services for underserved and uninsured
populations, for example, the Indian Health Service (IHS) and the Health Resources and Services
Administration (HRSA). Several PHS agencies fund health programs at the state, local, tribal, and
territorial (SLTT) level.
Rescissions
PHS agencies received roughly $415 billion from the five COVID-19 supplemental appropriations
measures enacted in 2020 and the American Rescue Plan Act of 2021 (ARPA; P.L. 117-2) budget
reconciliation measure. Much of this funding was made available for multiple years or until expended.
While the majority of funds were made available specifically for activities related to the COVID-19
pandemic, some of the ARPA appropriations were made available for broader purposes. FRA rescinds
selected unobligated balances, as explained in the next sections.
Rescissions from COVID Supplemental Appropriations
FRA rescinds selected unobligated balances of COVID-19 supplemental appropriations enacted in 2020
from the following accounts:
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• Public Health and Social Services Emergency Fund Account (PHSSEF). The
PHSSEF account under the Office of the Secretary received appropriations for many
purposes: the Provider Relief Fund; vaccine, treatment, and other medical supply
research, development (R&D), and purchase; testing, contact tracing, and surveillance;
payments for COVID-19 testing for the uninsured; and other emergency response and
health services programs. Several laws included transfers from the PHSSEF account to
other PHS agencies, such as IHS and HRSA (see CRS report table). FRA rescinds
unobligated PHSSEF balances from all five relief laws, while preserving at least $2.9
billion in the account. Some of the remaining amount is designated for specific purposes;
for example, $300 million remains available to the Provider Relief Fund for “necessary
expenses for program administration and oversight.” In addition, FRA preserves certain
transfers to the HHS Office of the Inspector General and the Covered Countermeasures
Process Fund.
• CDC-Wide Activities and Program Support. This CDC account received
appropriations for public health activities, such as SLTT public health grants; global
health; testing, epidemiology and surveillance; and vaccine distribution and tracking.
FRA rescinds unobligated balances from the three laws that appropriated to this account,
while preserving a total balance of $818 million along with transfers made to the
Infectious Diseases Rapid Response Reserve Fund.
• NIH/National Institute of Allergy and Infectious Diseases (NIAID). NIAID received
$836 million from the first COVID-19 supplemental (P.L. 116-123) for COVID-19
research (with a $10 million transfer to the National Institute of Environmental Health
Sciences for worker-based training to reduce COVID-19 exposure). FRA rescinds all
remaining unobligated balances.
Rescissions from American Rescue Plan Act (ARPA) Appropriations
FRA rescinds unobligated balances from certain ARPA public health sections (shown in parentheses),
which were provided to the following HHS agencies and accounts:
• PHSSEF: R&D, manufacturing and purchase of vaccines, treatments, and tests and other
medical supplies (2303), with exception of $69 million; testing, contact tracing, and
mitigation (2401), excepting $7.323 billion; Medical Reserve Corps (2502); public health
workforce programs (2501); and rural provider funding (9911).
• CDC: vaccine distribution activities (2301), with exception of $103 million; vaccine
confidence (2302); genomic sequencing and surveillance (2402), excepting $714 million;
awareness campaign for health professionals (2704); and global health (2403).
• HRSA: federal health centers (2601); health workforce programs (2602, 2603, 2604,
2703), Title X family planning (2605); behavioral health programs for health
professionals (2705, 2711); pediatric mental health (2712); and the Maternal, Infant, and
Early Childhood Home Visiting Program (9101).
• Defense Production Act (DPA) Medical Supplies Enhancement: for DPA actions
related to medical supplies (3101), excepting $793 million.
Effect of Recissions
The Congressional Budget Office (CBO) has estimated the following effect of FRA rescissions by agency
and account from all six relief laws, including transfers:
• PHSSEF: $9.9 billion

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• CDC: $1.5 billion
• NIH: $0.5 billion
• DPA Medical Supplies Enhancement: $0.9 billion
• HRSA: $0.3 billion
• FDA: $0.1 billion
Other HHS accounts with balances of less than $50 million would also be affected and may not be
reflected in the CBO score. These rescissions affect unobligated balances. Funds obligated, but not yet
fully expended—such as some multiyear SLTT public health grants—would not be affected.
It is currently difficult to assess the full scope of programs affected by the rescissions. Based on available
information, the following programs are known to have been affected:
• HRSA has stated that the Provider Relief Fund will make no further payments to
providers, including reconsideration payments. In addition, claim payments will not be
made under the Uninsured Program or the Coverage Assistance Fund.
• CDC has indicated that the last two years of a five-year Disease Intervention Specialist
workforce grant will no longer be available to grantees.
• IHS has indicated that $419 million in transfers the agency received were rescinded.
• A stakeholder letter indicated that $84 million was rescinded from PHS Commissioned
Corps programs.
Potential Future Funding Implications
Several PHS agencies and funded SLTT health agencies are likely to see a funding “cliff” as pandemic
supplemental funding ends. Observers have recounted a “boom and bust cycle” where certain public
health agencies see increases during emergencies and decreases following them. Several analyses have
attributed challenges in the U.S response to the COVID-19 pandemic to inadequate or variable public
health funding preceding the pandemic, including those by The Commonwealth Fund, The National
Academy of Medicine, the Bipartisan Policy Center, and the Center for Strategic and International
Studies.
Some Members of Congress have argued that certain PHS agencies should not see increased funding
without further reform and oversight. In addition, some have argued that certain PHS agencies—
especially CDC—should be streamlined and refocused on “core” functions. In addition, funding alone
may not address all SLTT public health capacity issues. For example, a recent analysis found that some
jurisdictions have faced legal and institutional challenges in using ARPA grant funding to hire more
public health staff.

Author Information

Kavya Sekar

Analyst in Health Policy

Congressional Research Service
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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 subject to copyright protection in the United
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