In 2010, Section 4002 of the Patient Protection and Affordable Care Act (ACA. P.L. 111-148, as amended) established a new Prevention and Public Health Fund (PPHF).¹ Prior to enactment, public health advocates had sought a guaranteed federal investment in prevention and wellness that was not subject to the annual appropriations process.² The PPHF ACA Section provides a permanent annual mandatory appropriation,³

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.

This CRS report provides an overview of the PPHF since ACA enactment, including its legislative and policy history. The report also provides an analysis examining whether the PPHF has provided for expanded investment in public health and prevention as authorized in statute.

PPHF appropriations are mandatory spending meaning that the authorizing law that establishes the PPHF also provides an appropriation of funds each fiscal year. The annual appropriation is permanent, meaning that the law is to provide an annual appropriation each fiscal year without a termination date.⁴ As enacted, the law began with $500 million appropriated in FY2010 with increasing amounts each subsequent fiscal year until $2 billion was to be appropriated in FY2015 and each year thereafter. Subsequent amendments have reduced the actual annual appropriations amounts (see Table 1).

Per the authorizing statute, the fund is to be administered through the Department of Health and Human Services (HHS) Office of the Secretary. The Secretary is to transfer fund amounts to increase funding over the FY2008 level for "prevention, wellness, and public health activities including prevention research, health screenings, and initiatives, such as the Community Transformation grant program, the Education and Outreach Campaign Regarding Preventive Benefits, and immunization programs."⁵ Since FY2014, annual appropriations laws have limited this transfer ability as discussed in this report.

For FY2010 through FY2013, the HHS Secretary determined the distribution of PPHF funds, transferring the majority of total PPHF appropriations for those years to the Centers for Disease Control and Prevention (CDC) as shown in Table 2.

For FY2013, the Secretary used almost half of the available PPHF appropriation to implement ACA insurance exchanges, prompting objections from both supporters and opponents of the fund.⁶ Since FY2014, Congress has determined annual PPHF allocations using the annual appropriations process, providing most of each annual appropriation to the CDC also shown in Table 2.

Congressionally determined PPHF allocations for specific HHS programs have remained fairly consistent since FY2014 as shown in Table 3.

The PPHF currently provides one source of budget authority for certain HHS agencies that also receive discretionary budget authority. In this report, CRS explores whether the PPHF has effectively increased federal public health funding since enactment. Using CDC as a main example, CRS analysis shows that the CDC has not seen an overall increase in its program funding level after FY2010 when adjusting for inflation. From FY2011 though FY2023, the percentage of CDC's program level comprising PPHF transfers has ranged from 7.3% to 12.7%.

Prevention and Public Health Fund: Current Status

Table 1 provides a legislative history of PPHF appropriations, beginning with appropriations as enacted in the ACA, funding levels as amended, and then a summary of appropriations under current law. Current law amounts do not reflect reductions due to budget sequestration (see Table 2 for a summary of sequestrations).⁷ The rightmost column shows final PPHF total transfers made available each fiscal year after sequestration.

As shown in the table, in three years PPHF received the same funding level as originally enacted. In most years, PPHF has received less funding than originally enacted.

Congress has further specified PPHF allocations through annual appropriations laws in recent years. Figure 1 shows PPHF allocations for FY2023 as directed in the explanatory statement accompanying the FY2023 Departments of Labor, HHS, and Education and Related Agencies (LHHS) appropriations law.

Figure 1. PPHF Allocations in FY2023 LHHS Appropriations From the Explanatory Statement Accompanying FY2023 appropriations

Source: "Explanatory Statement Accompanying Consolidated Appropriations Act, 2023," Congressional Record, vol. 168 (December 20, 2022), p. S8895. Notes: ACL= Administration for Community Living; CDC= Centers for Disease Control and Prevention; SAMHSA= Substance Abuse and Mental Health Services Administration.

As shown, most of the post-sequester PPHF funding went to CDC ($903.3 million total) with smaller amounts for the Substance Abuse and Mental Health Services Administration (SAMHSA; $12 million) and the Administration for Community Living (ACL; $27.7 million total).⁸ The FY2023 appropriations law required the Secretary to transfer FY2023 PPHF funds in accordance with the table in the explanatory statement and prohibited further transfers.⁹

Prevention and Public Health Fund: History

Before and During Enactment

Public health advocates had previously sought a guaranteed federal investment in prevention and wellness that was not subject to the annual appropriations process.¹⁰ Prior to enactment of the ACA, a House-reported health care reform bill (H.R. 3200, 111^th Congress) would have established a prevention and wellness trust that authorized annual appropriations for specific activities. Additionally, the Senate Committee on Health, Education, Labor and Pensions (HELP) had originally proposed $80 billion in mandatory appropriations over the first 10 years for the PPHF in the committee-reported bill (S. 1679, 111^th Congress). The final ACA text included $15 billion in mandatory appropriations over the first ten years.¹¹ The final ACA text was not accompanied in either chamber by committee reports that would have further clarified policy intentions for the PPHF.

FY2010-FY2013: HHS Secretary Determined Allocations

From FY2010 through FY2013, the HHS Secretary determined how PPHF funds were allocated as shown in Table 2.

As noted earlier, the PPHF authorizing statute allowed the HHS Secretary to allocate funds for "prevention, wellness, and public health activities including prevention research, health screenings, and initiatives, such as the Community Transformation grant program, the Education and Outreach Campaign Regarding Preventive Benefits, and immunization programs."¹² The statute also granted the House and Senate Appropriations Committees authority to transfer funds for eligible activities authorized in the PPHF statute.¹³

The Secretary generally used the PPHF to fund a mix of preexisting activities and activities newly authorized under the ACA. For example, in FY2012, the HHS Secretary allocated some of the PPHF funding to CDC programs that predated the ACA, including viral hepatitis programs ($10 million), immunization programs ($190 million), and tobacco use prevention programs ($83 million), among others. The Secretary also allocated funding toward new ACA programs, for example, in FY2012, HHS allocated $226 million of the PPHF toward CDC Community Transformation grants authorized in ACA Section 4201.¹⁴ Through this program, CDC funded state and local health agencies and organizations to implement community intervention projects that involved cross-sectoral approaches to improving health, such as through promoting better sidewalks for safe walking or by supporting local farmers to increase access to healthy food.¹⁵ Some Members of Congress raised concerns with this use of the PPHF and also with the scope of the HHS Secretary's ability to allocate funds.¹⁶

Much of the funding in FY2010 through FY2012 went to CDC and the Health Resources and Services Administration (HRSA) for public health and health workforce programs respectively. As noted, in 2013, $454 million of the PPHF was allocated to support health insurance enrollment at the Centers for Medicare & Medicaid Services (CMS).¹⁷ According to the PPHF FY2013 report,¹⁸

Studies have also shown that insurance coverage can lead to better health. It helps people obtain the primary care, preventive services, prescription drugs and mental health services they need to stay healthy, prevent disease before it starts or stop it from worsening. Those who are uninsured are less likely to get recommended screenings (e.g. mammograms and colonoscopies) or have a regular source of care, and generally have poorer control of chronic conditions such as hypertension. New coverage options available in the Marketplaces will increase access to preventive care and help improve health outcomes for the millions of individuals who will be able to enroll in affordable health plans. Assisting these individuals in gaining affordable health care aligns with the purpose of the Prevention Fund - to support the necessary infrastructure to prevent disease, detect it early, and manage conditions before they become severe, and help states and communities promote healthy living.

As noted earlier, CMS's use of the fund for health insurance program purposes prompted objections from both supporters and opponents of the fund.¹⁹

FY2014-FY2023: Congress Determined Allocations

Starting in FY2014 appropriations, Congress began to direct PPHF allocations through annual LHHS appropriations laws.²⁰ In FY2014, the congressionally directed PPHF allocations mostly went toward programs that the HHS Secretary had previously funded using PPHF appropriations. Congress stopped funding certain PPHF-funded programs, including the CDC Community Transformation Grants program.²¹ Since FY2014, Congress has specified PPHF allocations through report or explanatory statement tables accompanying appropriations laws (see example in Figure 1) and has prohibited further transfers through general provisions in LHHS appropriations acts.

As shown in Table 3, congressionally directed PPHF allocations have been fairly consistent since this practice began. Most of the allocations have gone toward HHS programs within CDC, SAMHSA, and ACL, including some established by the ACA. In many cases, the same programs that receive PPHF transfers also receive some discretionary appropriations.²² For example, in FY2023, PPHF transfers accounted for about 27% of the funds for the Garrett Lee Smith suicide prevention grants to states, administered by SAMHSA.²³ For some programs, the PPHF contribution made up more than half of total program funding in FY2023. Examples include the CDC immunization program (61%) and tobacco prevention activities (51%). Some programs are funded entirely by PPHF transfers. For example, the CDC Preventive Health and Health Services Block Grant program received 100% of its FY2023 funding from the PPHF.²⁴

PPHF Amendments as an Offset

As shown in Table 1, the PPHF has been amended five times since enactment. In most of these laws, the PPHF amendments were included in "offset" or "savings" portions of the laws. As mentioned, one law that amended the PPHF provided increases to the appropriations in some years, but still had the overall net effect of decreasing future PPHF appropriations (P.L. 115-123, §53119). In total, these laws have had the effect of reducing total appropriations made available in the PPHF ACA section as shown in Table 1.

Has the PPHF Increased Funding for Public Health and Prevention?

Per its statutory authorization, the PPHF is to "provide for expanded and sustained national investment in prevention and public health programs." Public health stakeholders have argued that the PPHF has been used to supplant rather than supplement discretionary appropriations for the CDC and other HHS agencies.²⁵

Figure 2 shows a CRS analysis of CDC's core public health program funding levels as adjusted for inflation from FY2005 through FY2023 with the percentage of the overall program level comprised of PPHF allocations.²⁶ Because CDC has received the largest portion of PPHF funds throughout the fund's history, the agency can serve as a main example for examining whether the PPHF has provided for expanded investment in public health.

The analysis shows that CDC saw a slight increase in its overall program level in the first year the agency received PPHF transfers in FY2010: $9.62 billion in FY2010 compared to $9.45 billion in FY2009. Since then, CDC's inflation-adjusted program level has varied from year to year. From FY2011 though FY2023, the percentage of CDC's program level comprising PPHF transfers has ranged from 7.3% to 12.7%. During the same period, CDC's total program funding level has not exceeded FY2010 levels when adjusting for inflation. Thus, CDC has not seen an overall inflation-adjusted increase in its program level since PPHF enactment.

Figure is interactive in the HTML version of this report.

Source: CRS analysis drawing on data from CDC Congressional Budget Justifications from FY2007 to FY2024. "All Purpose Table," accessed at https://www.cdc.gov/budget/congressional-justifications/index.html. GDP Deflator index values from FRED, Gross Domestic Product: Implicit Price Deflator, Accessed at https://fred.stlouisfed.org/series/GDPDEF.

Notes: Amounts reflect final appropriations after transfers and other adjustments and may therefore differ from amounts as enacted. Amounts shown may not reflect all post-appropriations transfers. CDC's other budget sources comprise discretionary budget authority for CDC and the Agency for Toxic Substances and Disease Registry (ATSDR), other transfers, and one-time mandatory appropriations the agency received for public health programs. Amounts shown do not include emergency supplemental appropriations (e.g., Coronavirus Disease 2019 supplemental appropriations) or other one-time appropriations such as those provided in The American Rescue Plan Act. The core public health program level does not include other mandatory appropriations that CDC receives for specific health services programs, such as for the Vaccines for Children program and the World Trade Center Health Program. For more background, see CRS Report R47207, Centers for Disease Control and Prevention (CDC) Funding Overview.

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.

Concluding Observations

As with the ACA as a whole, the PPHF has sparked some controversy. In the immediate years following enactment, there were concerns as to the broad discretion of the Secretary to administer a sizeable permanent appropriation and also around specific uses of the fund, such as for community infrastructure projects and ACA health insurance implementation activities.²⁷ As noted, since FY2014, annual appropriations laws have limited the HHS Secretary's discretion in allocating the fund. Since the ACA was enacted in 2010, Congress has considered several proposals to repeal the fund and rescind any unobligated balance.²⁸

Since FY2014, Congress has directed annual PPHF allocations to HHS agencies. The PPHF currently provides one source of budget authority for certain HHS agencies that also receive discretionary budget authority. The programs that have received PPHF funding have remained relatively consistent since FY2014 as shown in Table 3. In this report, CRS has explored whether the PPHF has increased public health funding since enactment. Using CDC as a main example, CRS analysis shows that the CDC has not seen an overall increase in its program funding level after FY2010 when adjusting for inflation. From FY2011 though FY2023, the percentage of CDC's program level comprising PPHF transfers has ranged from 7.3% to 12.7%.

Public health advocates have opposed further PPHF recissions. For example, in September 2023, a group of 111 health organizations sent a letter to the Senate HELP Committee opposing further PPHF recissions in proposed legislation (S. 2840).²⁹ The letter stated, "The Prevention Fund currently comprises more than 10 percent of the Centers for Disease Control and Prevention's (CDC) entire annual operating budget. Cuts to the Prevention Fund will translate into funding shortfalls in programs that states have long relied upon to keep their residents healthy and safe."

If providing additional support for public health and prevention remains a priority, Congress could consider whether the PPHF has had the desired effect as currently structured. Congress could examine whether statutory changes might help the fund achieve intended policy goals, for example, by further specifying programs eligible to receive PPHF funding. Congress could also examine the role of agency discretion in the fund's history, and whether more or less agency discretion is desirable moving forward. Congress could also consider whether greater oversight mechanisms might ensure that the fund is spent as intended.

Alternatively, if Congress decides to repeal or rescind PPHF appropriations, Congress could consider the overall effect on CDC and other HHS agency budgets. In recent years, PPHF has become one source of budget authority for CDC, SAMHSA, and ACL. If PPHF were repealed entirely or reduced below FY2023 levels, all else being equal, these agencies would see decreases in their annual program funding levels relative to current levels.