Introduction

The Centers for Disease Control and Prevention (CDC) 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 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 disease outbreaks and public health emergencies, including the federal response to the Coronavirus Disease 2019 (COVID-19) pandemic. The Agency for Toxic Substances and Disease Registry (ATSDR), a separate operating division headed by the CDC Director, is tasked with identifying potential public health effects from exposure to hazardous substances.

CDC focuses on supporting science-based disease prevention and health promotion on a population-wide basis. 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 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. Most of CDC's programs are authorized in the Public Health Service Act (PHSA). Many CDC programs and activities are not explicitly mentioned in the PHSA, but CDC carries out those programs on the basis of general and permanent statutory authorities granted to the HHS Secretary.⁴ Some CDC programs have specific authorizations, mostly in the PHSA.

Given CDC's mix of general and specific authorizations, appropriations play a central role in guiding the agency's policy priorities.

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 state⁵ and local health departments.⁶ 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 FY2023 to FY2025 and its funding history for core public health programs from FY2011 to FY2025. It also discusses CDC supplemental and emergency reserve funding. 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/pdf/organization/cdc-org-chart.pdf, updated as of February 23, 2023. Notes: HIV = Human Immunodeficiency Virus; STD = Sexually Transmitted Disease; TB = Tuberculosis; OPDIV = Operating Division.

Understanding CDC Funding

This CRS report divides CDC's annual program level⁷ into two categories, as shown in Figure 2:

• 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 the mandatory Prevention and Public Health Fund (PPHF), and
• other mandatory programs, including CDC-administered health services, compensation-related, and 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" in this CRS report aligns with the "CDC/ATDSR program level" presented in FY2025 CDC budget documents.⁸

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 Center Health Program (WTCHP)—primarily finance specific health services for eligible populations. Changes in annual spending 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.⁹

Figure 2. FY2024 Enacted Centers for Disease Control and Prevention Program Level by Category and Budget Authority Thousands of Dollars

Source: FY2024 discretionary amounts are from P.L. 118-47 and Congressional Record, vol. 170, no. 51 (March 22, 2024), H2020-H2022, and other mandatory program amount estimates from CDC, "FY2025 Budget Detail Table," https://www.cdc.gov/budget/documents/fy2025/FY-2025-CDC-Budget-Detail.pdf. Notes: Amounts reflect some post-appropriations adjustments. Acronyms: CDC = Centers for Disease Control and Prevention.

Core Public Health Program Level

CDC's core public health program level funds the main programs that CDC CIOs implement in their efforts to prevent and control disease and to improve public health. 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 and supporting public health laboratory capacity; supporting and conducting health education and promotion efforts; funding, 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 fund and support public health activities at the state and local level.¹⁰

CDC's core public health program level is made up of (1) discretionary appropriations; (2), mandatory funding from the Prevention and Public Health Fund (PPHF); and (3) some other funding sources, such as transfers from other accounts.

Discretionary Funding (FY2024: $7.938 billion in LHHS budget authority; $82 million for ATSDR). CDC receives discretionary funding through annual LHHS appropriations, while ATSDR is separately funded by Interior/Environment appropriations. Within LHHS appropriations, CDC receives funding in several accounts, many of which align with CDC CIOs. Some accounts fund activities through multiple CIOs (e.g., the Public Health Scientific Services account). 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 Birth Defects, Developmental Disabilities, Disabilities and Health account funds activities at CDC's National Center on Birth Defects and Developmental Disabilities (NCBDDD). The appropriations act text provides funding to the 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 FY2024 LHHS Appropriations

Source: Consolidated Appropriations Act, 2024, P.L. 118-47, Division D, Title II.

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 FY2024 report language and funding table accompanying the Birth Defects and Developmental Disabilities appropriation.¹¹

Figure 4. Example of CDC Appropriations Report Language

Source: "Explanatory Statement Accompanying Consolidated Appropriations Act, 2024," Congressional Record, vol. 170 (March 22, 2024), p. H1889.

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.¹² In addition, the appropriations reports include many directives or recommendations from Congress to CDC regarding funded programs.

Mandatory Funding from the Prevention and Public Health Fund (PPHF) (FY2024 funding: $1.186 billion). In recent years, some CDC LHHS accounts have received annual allocations of the mandatory PPHF as directed in LHHS appropriations laws. In 2010, the Affordable Care Act (ACA; P.L. 111-148, as amended) established the PPHF, which is a permanent, annual appropriation that was intended to provide support prevention, wellness, and related public health programs funded through HHS accounts.¹³ 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 laws and accompanying report language.¹⁴ See Figure 5 for PPHF allocations from FY2024 appropriations.

Figure 5. Example of Prevention and Public Health Fund Allocations From FY2024 LHHS Appropriations

Source: "Explanatory Statement Accompanying Consolidated Appropriations Act, 2024," Congressional Record, vol. 170 (March 22, 2024), p. H1894.

As shown in Figure 5, most of the FY2023 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).

Public Health Service Evaluation Tap (FY2024: $43 million). The PHS Evaluation Set-Aside, also known as the PHS Evaluation Tap, has the effect of redistributing a certain percentage of eligible appropriations among HHS accounts funded by the LHHS Act (up to 2.5% of eligible appropriations in FY2024).¹⁵ Eligible appropriations potentially subject to the transfer include any provided for programs authorized in the Public Health Service Act, with some exemptions.¹⁶ In recent years, appropriations laws have directed specific amounts of PHS tap funds to specific agencies. Until FY2024, CDC had not received directed PHS tap transfers since FY2014 (see Figure 6). By convention, appropriations acts direct where specified PHS tap transfers are to be allocated, but do not specify the accounts that are to be the sources of those transfers. Thus, tables in this report show only the amount of PHS tap funds received in any CDC account, and not the amount transferred out of source accounts.

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. For example, as shown in Figure 6, CDC has received occasional transfers from the Public Health and Social Services Emergency Fund (PHSSEF).¹⁷

Smaller mandatory appropriations for core public health programs. Some smaller CDC public health programs have been funded by mandatory budget authorities, such as for the Childhood Obesity Demonstration Project,¹⁸ as authorized in Social Security Act (SSA) Section 1139A(e)(8).¹⁹

Other Mandatory Programs

CDC also administers several health services and compensation-related programs that are funded by mandatory budget authorities and are distinct from the agency's core public health programs. In several 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 fee programs.

The Vaccines for Children (VFC) program (FY2024 estimate: $7.213 billion) provides vaccines to enrolled health care providers to vaccinate eligible children.²⁰ 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.²¹ VFC is financed by a Medicaid appropriation within the HHS Centers for Medicare & Medicaid Services (CMS) and is administered by CDC.²² 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 as required by the program's authorization law.²³

The Energy Employees Occupational Illness Compensation Program (EEOICP) (FY2024 estimate: $51 million), administered by the Department of Labor (DOL), 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.²⁴ CDC provides support to the program by conducting radiation dose estimates, evaluating certain petitions, and providing other administrative support. DOL uses these estimates in making compensation determinations.²⁵ Annual funding for these CDC activities is 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 funding).²⁶

The World Trade Center Health Program (WTCHP) (FY2024 estimated obligations: $768 million) provides medical monitoring and treatment to eligible individuals directly affected by the September 11, 2001 attacks for certain incident-related health conditions. This program also funds medical research into health conditions that may develop due to exposure during the attacks.²⁷ The program is authorized by PHSA Title XXXIII (42 U.S.C. §§300mm et seq.) and funded through appropriations provided by PHSA Section 3351 (42 U.S.C. §300mm–61).

User fee programs (FY2024 estimate: $2.226 million). CDC also receives relatively small amounts of user fees from authorized user fee programs such as the vessel sanitation program,²⁸ which collects fees from cruise ship owners for public health inspections. In addition, the respirator certification program charges fees to respirator manufacturers for certain regulatory activities.²⁹

Proposed Mandatory Programs

The Biden Administration proposed new mandatory programs in the FY2025 budget request, summarized below.³⁰ Estimated amounts for those programs are summarized in Table 1 where applicable.

• Pandemic Preparedness. For FY2025, President Biden's budget proposes $6.100 billion in public health preparedness funding as a transfer to CDC from $20.000 billion appropriated to the Public Health and Social Services Emergency Fund, to be made available for five years. The FY2025 proposed public health preparedness funding is presented as a non-add in the President's budget and is therefore not included within the FY2025 total program level for CDC.
• Vaccines for Adults Program. According to the request, CDC submitted a legislative proposal for mandatory funding of $1.004 billion in FY2025 for a capped mandatory program to provide vaccines to adults. As requested, $12 billion would be provided for the program over 10 years.
• VFC program modifications. Similar to the FY2024 request, the CDC proposes some legislative changes to VFC, including expanding eligibility 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. Both of those changes would affect annual VFC funding. The FY2025 requested amount for VFC in Table 1 does not reflect all the proposed program modifications.
• Community Violence Intervention: The request proposes $150 million in mandatory funding for a Community Violence Intervention Initiative, in addition to $100 million in discretionary funding. According to CDC, "This investment will support scaling up existing community violence prevention efforts and implementing and evaluating programs, policies, and practices based on the best available evidence for preventing community violence."³¹

Funding Table

Table 1 provides an overview of CDC/ATSDR budget and appropriations for FY2023 enacted through the FY2025 budget request, reflecting all sources of regular budget authority (excludes supplemental appropriations).

Trends in Core Public Health Program Level

As shown in Figure 6, in terms of nominal dollars, from FY2011 to FY2021, CDC's core public health program level remained mostly between $6.5 and $8 billion until the increases provided in FY2022 (+9.0%) and FY2023 (+11.2%; 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.³² CDC saw an overall decrease in its program level in FY2024 (-1.8%). The FY2025 request would provide an increase of 5.6%.

FY2011-FY2024 final, FY2025 request ($ in billions, nominal)

(Figure is interactive in the HTML version of this report.)

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

Notes: Amounts are not adjusted for inflation. *President's budget request; does not reflect proposed mandatory preparedness funding. Acronyms: CDC = Centers for Disease Control and Prevention; LHHS = Labor, Health and Human Services, Education, and Related Agencies appropriations bill; 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; ACA = Affordable Care Act.

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 and P.L. 117-328), the Coronavirus Disease 2019 (COVID-19) pandemic,³³ medical screening and supports for Afghan refugees (P.L. 117-70), and funding for domestic and global activities related to the war in Ukraine (e.g., P.L. 117-128). These amounts are not reflected in the other sections of this report as they are not intended to fund the agency's regular operating expenses and programs. 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 spent $600 million on its public health response and also administered $1.4 billion through its Public Health Emergency Response grant program to state and local partners.³⁴ 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.³⁵ 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 more than $114 million through the Epidemiology and Laboratory Capacity (ELC) grant program.³⁶
• 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.³⁷ CDC obligated a portion of the funding to state and local agencies through several grant programs, including more than $184 million through the ELC grant program.³⁸
• 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.³⁹ Some of 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 instead was made available for general public health capabilities, see example of the Public Health Infrastructure grant program in the textbox below. In addition, CDC has received at least $1 billion in transfers and has administered more than $40 billion through its grant programs funded by HHS appropriations from the PHSSEF account.⁴⁰ As a result, of the total appropriated to and administered by CDC, $59.525 billion in CDC COVID-19 grants have been awarded to state, tribal, and local agencies as of September 2023 (amount includes some regular appropriations).⁴¹ 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.

Some of the COVID relief dollars have since been rescinded. The Congressional Budget Office estimated that the Fiscal Responsibility Act (P.L. 118-5) rescinded $1.5 billion in CDC budget authority. In addition, FY2024 appropriations rescinded certain American Rescue Plan Act appropriations for public health; the full impact on CDC is unclear from publicly available sources.⁴²

Congress often appropriates emergency supplemental funding to HHS for purposes that are somewhat general, or with the authority for HHS to transfer those funds, 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

FY2019 appropriations (P.L. 115-245) established an Infectious Diseases Rapid Response Reserve Fund (IDRRRF) at CDC.⁴³ 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

• 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.⁴⁴

Since FY2019, the IDRRRF has received the following regular and supplemental appropriations shown in Table 2.

IDRRRF funding has been used for multiple responses, including for recent Ebola outbreaks in Africa, the mpox outbreak in 2022-2023, and for the COVID-19 pandemic response.⁴⁵ As of May 2024, the IDRRRF has an unobligated balance of $550.5 million available for infectious disease emergencies.⁴⁶

Other reserve fund accounts outside of CDC can also support public health emergency response. These include the (1) Public Health Emergency Fund [PHSA Section 319(b), 42 U.S.C. §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 $56,500 and has not received appropriations for many years.⁴⁷ 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 2009, the Ebola virus outbreak in 2014, and the Zika virus outbreak in 2016.⁴⁸ Congress subsequently established the IDRRRF in 2018.