Boom, now bust: Budget cuts and layoffs take hold in public health

This is a KFF Health News story.

Even as federal aid poured into state budgets in response to the COVID-19 pandemic, public health leaders warned of a boom-and-bust funding cycle on the horizon as the emergency ended and federal grants sunsetted. Now, that drought has become reality and state governments are slashing budgets that feed local health departments.

Congress allotted more than $800 billion to support states' COVID-19 responses, fueling a surge in the public health workforce nationwide.

Local health department staffing grew by about 19% from 2019 to 2022, according to a report from the National Association of County and City Health Officials that studied 2,512 of the nation's roughly 3,300 local departments. That same report explained that half of their revenue in 2022 came from federal sources.

But those jobs, and the safety net they provide for the people in the communities served, are vulnerable as the money dries up, worrying public health leaders – particularly in sparsely populated, rural areas, which already faced long-standing health disparities and meager resources.

Officials in such states as Montana, California, Washington and Texas now say they face budget cuts and layoffs. Public health experts warn that the accompanying service cuts – functions like contact tracing, immunizations, family planning, restaurant inspections, and more – could send communities into crisis.

In California, Democratic Gov. Gavin Newsom proposed cutting the state's public health funding by $300 million. And the Washington Department of Health slashed more than 350 positions at the end of last year and anticipated cutting 349 more this year as the state's federal COVID-19 funding runs dry.

"You cannot hire firefighters when the house is already burning," said Brian Castrucci, president and CEO of the de Beaumont Foundation, an organization that advocates for public health policy.

In some places, that pandemic cash did little more than keep small health departments afloat. The Central Montana Health District, the public health agency for five rural counties, did not receive the same flood of money others saw but did get enough to help the staff respond to an increased workload, including testing, contact tracing and rolling out COVID-19 vaccines.

The department filled a vacancy with a federal grant funneled through the state when a staffer left during the pandemic. The federal funding allowed the department to break even, said Susan Woods, the district's public health director.

Now, there are five full-time employees working for the health district. Woods said the team is getting by with its slim resources, but a funding dip or another public health emergency could tip the balance in the wrong direction.

"Any kind of crisis, any kind of, God forbid, another pandemic, would probably send us crashing," Woods said.

Adriane Casalotti, chief of government and public affairs for the National Association of County and City Health Officials, said she expects to see layoffs and health department budget cuts intensify. Those cuts will come as health officials address issues that took a back seat during the pandemic, like increases in rates of sexually transmitted diseases, suicide, and substance misuse.

"There's tons of work being done right now to pick up the pieces on those types of other public health challenges," she said. But it'll be hard to catch up with whittled resources.

From 2018 to 2022, reports of chlamydia, gonorrhea, syphilis and congenital syphilis increased by nearly 2% nationwide, adding up to more than 2.5 million cases. A recent KFF report found that routine vaccination rates for kindergarten-age children have not rebounded to pre-pandemic levels, while the number of families claiming exemptions has increased. Nearly three-quarters of states did not meet the federal target vaccination rate of 95% for the 2022-23 school year for measles, mumps, and rubella, increasing the risk of outbreaks.

Amid these challenges, public health leaders are clinging to the resources they gained during the past few years.

The health district in Lubbock, Texas, a city of more than 250,000 people in the state's Panhandle, hired four disease intervention specialists focused on sexually transmitted diseases during the pandemic due to a five-year grant from the Centers for Disease Control and Prevention (CDC).

The positions came as syphilis cases in the state skyrocket past levels seen in the past decade and the increases in congenital syphilis surpass the national average, according to the CDC. State officials recorded 922 congenital syphilis cases in 2022, with a 246.8 rate per 100,000 live births.

But federal officials, facing their own shrinking budget, cut the grant short by two years, leaving the district scrambling to fill a nearly $400,000 annual budget gap while working to tamp down the outbreak.

"Even with the funding, it's very hard for those staff to keep up with cases and to actually make sure that we get everybody treated," said Katherine Wells, director of public health for Lubbock.

Wells said state officials may redirect other federal money from the budget to keep the program going when the grant ends in December. Wells and other health leaders in the state consistently plead with state officials for more money but, Wells said, "whether or not we'll be successful with that in a state like Texas is very much in the air."

Making public health a priority in the absence of a national crisis is a challenge, Castrucci said. "The boom-and-bust funding cycle is a reflection of the attention of the American public," he said; as the emergency sunsetted, so too did enthusiasm wane for public health issues.

And rural health departments, like the one in central Montana, deserve more attention, said Casalotti, the advocate for county and city health officials. That's because they serve a critical function in communities that continue to see hospital closures and lose other health services, such as maternity and women's care. Local health departments can function as a "safety net for the safety net," she said.