Breakthroughs Blog: US budget

On February 15, President Trump signed into law a bipartisan spending bill—averting another partial government shutdown and ensuring full-year funding for the government for the remainder of fiscal year (FY) 2019. The move followed several days of speculation about whether discord between Congress and the President on funding for a border wall would imperil the spending measure passed by Congress to fund the remaining one-quarter of the federal government.The months-long saga ended with some great news for global health and research and development (R&D)—a roughly US$150 million funding increase for global health programs in the State and Foreign Operations (SFOPs) bill, as well as a significant boost to the Food and Drug Administration (FDA) under the Agriculture bill included in the package.The bill included some welcome increases to global health accounts which have been flat-funded for five years running, including a $50 million (1.16 percent) increase to the President’s Emergency Plan for AIDS Relief (PEPFAR) and a $2.5 million (2.5 percent) increase to the US Agency for International Development’s (USAID) Neglected Tropical Disease Program compared to FY 2018. Nutrition saw a $20 million (16 percent) increase and Maternal and Child Health got a $5.5 million (0.66 percent) boost. But perhaps the most notable win in the bill was a long-sought increase to USAID’s tuberculosis (TB) program. After TB was in the spotlight at the United Nations High-Level Meeting on TB in September, the United States backed up its pledge of additional support for the global fight against TB by including a $41 million (15.71 percent) increase to the program in the final spending package for FY 2019—the largest increase to the program in more than five years. All other global health accounts were level-funded compared to FY 2018, resulting in an overall increase of 3.23 percent for USAID Global Health—a stark difference from the 36 percent cut proposed in the President’s budget.While most accounts of relevance to global health R&D within the Department of Health and Human Services were funded for the entire fiscal year in a spending package passed in September, the FDA was one agency whose funding was still in limbo. The FDA’s unique funding structure—divided between budget authority, or discretionary funding (appropriated by Congress), and fees (paid by FDA users) —shielded the agency from some of the worst impacts of the partial government shutdown in December and January as it drew down on user fees to continue most operations. But the final FY 2019 funding package included a welcome $460 million (9 percent) increase for the agency, including a $269 million (9 percent) increase in budget authority.As the FY 2019 appropriations process lurched across the finish line, advocates were already gearing up for another budget battle for FY 2020. Check back for regular updates as appropriations hearings begin and GHTC continues monitoring the prospects for global health R&D accounts in the coming year.  For reference, the text of the Conference Report to accompany H.J. Res. 31, the Consolidated Appropriations Act, 2019, is available here, the text of the Joint Explanatory Statement is here (with the Global Health Program breakdown on page 454 of the PDF), and a division-by-division summary is available here.

This afternoon, President Trump signed into law a spending bill that pairs full-year fiscal year (FY) 2019 funding for Labor, Health and Human Services (LHHS) and Defense with a stopgap measure to keep other agencies funded through December—staving off a partial government shutdown on the eve of the end of the fiscal year. The “minibus”-plus-continuing resolution (CR) legislation boosts funding for medical research across the Department of Health and Human Services (HHS) for FY19, while maintaining funding for global health at the US Agency for International Development and the Department of State through December 7 via the CR measure. Given Trump already signed into law a spending package covering Energy, Veterans Affairs, and the Legislative Branch, now 75 percent of the government is funded for the full fiscal year; while the remaining agencies will remain funded through the CR as lawmakers work to finish full-year funding bills for them. While this year’s appropriations approach may be unusual, by recent historical standards, it was also remarkably efficient: Today marks the first time in 22 years that the government has succeeded in getting at least five of the twelve annual spending bills signed into law before the new fiscal year begins. Here’s a breakdown of how global health and medical research funding fared in the spending package: National Institutes of Health The National Institutes of Health received an impressive US $2 billion boost overall (a 5 percent increase over FY18), including increases of 3-9 percent to each center involved in global health research and development (R&D). In increasing order, the package provided a boost of 3.4 percent for the Fogarty International Center, 3.75 percent for the Eunice Kennedy Shriver National Institute of Child Health and Human Development, 5 percent for the National Institute of Allergy and Infectious Diseases, and 8.62 percent for the National Center for Advancing Translational Sciences. Centers for Disease Control and Prevention The Centers for Disease Control and Prevention (CDC) also saw an overall increase from FY18 – depending on how you do the math. In the FY18 omnibus appropriations bill passed in March, CDC received a one-time $480 million funding infusion to support the construction of a replacement Prevention Biosafety Level 4 high containment laboratory to enable continued research on dangerous pathogens like Ebola. Less the cost of that lab, CDC’s overall year-on-year budget rose 1.63 percent. The Center for Global Health was level-funded, while the National Center for Emerging and Zoonotic Infectious Diseases received a 1 percent bump. The bill also established a new CDC-wide Infectious Disease Rapid Response Reserve Fund with an initial infusion of $50 million, a key win for global health security advocates. Biomedical Advanced Research and Development Authority The Biomedical Advanced Research and Development Authority (BARDA) saw a $25 million budget increase in the bill (a 4.66 percent boost). This—coupled with the House passage of the Pandemic and All-Hazards Preparedness and Advancing Innovation Act of 2018—earlier this week, which reauthorized BARDA and authorized $250 million annually for five years for a new emerging infectious diseases program—is welcome news for those looking to BARDA to play an increasingly robust role in global health R&D. However, given the Senate still needs to pass their own version of a bill and continues to pursue a general all-hazards approach in their bill, a call out for emerging infectious diseases may not come to fruition in the final reauthorization. US Agency for International Development & State Department Global health accounts at the US Agency for International Development and the Department of State will be level funded through December 7 since the funding package signed into law today includes a CR for the State and Foreign Operations appropriations bill.   The bottom line: Yet again, strong congressional support has protected global health R&D from deep cuts to key agencies proposed in the President’s budget request and even won significant increases to some accounts. As we get closer to the midterm elections, we will keep a close eye on political developments that could affect our funding prospects for FY20.

Last Friday, President Donald Trump signed into law a US$1.3 trillion spending bill to fund the US government through the rest of fiscal year (FY) 2018. Reluctantly signed by the President among a flurry of “will he, won’t he” tweets, the legislation represents a forceful rebuke by Congress of the Administration’s proposal to drastically slash funding for global health and medical research programs. Key US agencies and programs that advance global health research and development (R&D) not only saw their funding protected in the spending bill, but many also saw increases. This outcome demonstrates that our community’s appeals and messages have not fallen on deaf ears and that Congressional policymakers on both sides of the aisle want to see the United States continue its leadership in advancing innovation to improve the health of those in need around the world. Here are some of the key takeaways from the 2,000+-page bill: US Agency for International Development & State Department While the Trump Administration proposed slashing funding for global health programs at the US Agency for International Development (USAID) and the State Department by 25 percent, Congress stood firm in protecting these programs. The bill ultimately sustained overall funding for these programs at FY17 enacted levels. A few programs received increases including a boost of $15 million for GAVI, the Vaccine Alliance; $20 million for tuberculosis (TB); and $15 million for maternal and child health. Funding for USAID HIV and AIDS programming and family planning at State and USAID, which the President proposed eliminating fully, was protected at FY17 levels. Congress also directed $135 million from repurposed Ebola emergency supplemental funding to support USAID’s global health security programs.   USAID plays a leading role in developing health technologies for low-resource settings through its various global health programs, so it is critical that these programs receive adequate funding, so they can continue to prioritize R&D among their other activities. In light of the President’s proposal for deep cuts to these programs, a combination of level funding for some programs and increases for others is a positive sign in the midst of a challenging budget environment. National Institutes of Health   Strong bipartisan support for the National Institutes of Health (NIH) continued for FY18. While the President proposed a 21 percent cut to NIH funding, the final spending bill instead provided the agency with an increase of $3 billion—8.8 percent—over FY17 levels. This represents a historic funding high for NIH in actual dollars with increases spread across various NIH institutes and programs. Notably, the National Institute of Allergy and Infectious Diseases received a 7.2 percent increase—39 percent above the President’s FY17 request—while the Fogarty International Center, which was targeted by the Administration for elimination, received a boost of 5.2 percent compared to FY17.   NIH is the world’s leading funder of R&D for neglected diseases, providing approximately 40 percent of total global funding, so any changes to its funding produce a ripple effect felt by global health research institutes and people around the world. It is encouraging to see Congress continue its record of bipartisan support for NIH and take action to strengthen our nation’s leadership in medical research. Centers for Disease Control and Prevention   The US Centers for Disease Control and Prevention (CDC) also received a plus up in the FY18 omnibus. The agency saw its funding increased by $1.1 billion—nearly 15 percent—over FY17 levels. This was in sharp contrast to the 16 percent cuts proposed by the Administration. The CDC Center for Global Health (CGH) received a 12 percent increase, compared to a 21 percent proposed cut. This included a $1.5 million boost for parasitic disease and malaria and a substantial increase of $50 million for global health security programming, which supports implementation of the Global Health Security Agenda (GHSA). Funding for global immunization and AIDS programming within CGH remained level. The National Center for Emerging and Zoonotic Infectious Diseases also received a more modest 5 percent increase over FY17 funding.   CDC plays a critical role in advancing technologies and improving health systems to better detect, prevent, and respond to infectious disease threats worldwide. There was much concern surrounding the FY18 budget for CDC as the agency is facing a funding cliff. CDC and USAID received $1 billion from the Ebola emergency supplement to fund GHSA, but this money is set to run out in 2019. As a result, the agency has already announced plans to scale back its GHSA work in 39 of 49 countries. While more funding is still needed to sustain these programs, and the agency has yet to clarify how it will adjust programming in light of its FY18 appropriations; it is promising to see Congressional appropriators recognize the value of CDC’s engagement in improving global health security. Biomedical Advanced Research and Development Authority   The Biomedical Advanced Research and Development Authority (BARDA), which develops medical countermeasures against health threats including emerging infectious diseases and antimicrobial resistance (AMR), also received a boost in the FY18 spending bill. The agency saw its funding increased by $25 million—about 5 percent—over FY17 levels.   BARDA has played an increasing role in R&D for naturally occurring threats and emerging infectious diseases in response to the Ebola and Zika epidemics. With its focus on bridging the “valley of death” in product development and its ability to use unique contracting mechanisms to forge innovative and long-term private-sector partnerships, BARDA is well positioned to make an impact in this space. However, the agency has been constrained by a lack of dedicated funding for its emerging infectious disease portfolio. While it is promising to see appropriators increase the agency’s overall funding for FY18, GHTC will be pushing for more dedicated funding for emerging infectious diseases in FY19. Department of Defense   The Department of Defense’s (DoD) activities in infectious disease research also saw increases in the omnibus. DoD’s Peer Reviewed Medical Research Program—a program that conducts research on AMR, diarrheal diseases, emerging infectious diseases, malaria, TB, and vaccine development for infectious diseases—received $330 million in funding, which is an increase of $30 million over FY17 levels.   The FY18 spending bill is a big win for global health R&D stakeholders and advocates, but this victory may only be temporary. The legislation funds the government through the end of September, and the Trump Administration has once against proposed drastic cuts to global health and medical-research programs for FY19. So while the ink dries on this year’s spending bill and we take a moment to celebrate, GHTC is already gearing up for another difficult battle ahead on next year’s budget.

  2018 is shaping up to be another important year for US policy related to global health and medical research. As Congress returns for a busy work session and the White House continues to roll out policy reforms, here are the top five issues GHTC will be following in 2018: 1. US funding for global health R&D President Trump’s fiscal year 2018 (FY18) budget proposal called for dramatic cuts to global health, medical research, and public health accounts across the National Institutes of Health, US Centers for Disease Control and Prevention, US Agency for International Development (USAID), and the Department of State. While legislators pushed back sharply on these proposed cuts, Congress has not yet passed final FY18 spending bills. This means that we still do not have a final picture of what US government funding for global health and medical research will look like for this year. As Congress tries to navigate budget caps and other pressures that may constrain overall government spending, GHTC will continue to advocate for strong, stable public funding for critical global health and medical research programs. We’re also looking ahead to the fiscal year 2019 (FY19) budget and appropriations process, and bracing for a proposal from President Trump that may include even more significant spending cuts than those proposed in FY18. Despite verbal acknowledgement from the Trump Administration that US global health and medical research programs remain critically important, as the Administration continues plans to streamline government activities and reign-in spending, we do not expect to see prioritization of these issues reflected in Administration-driven spending proposals. GHTC will closely monitor FY19 proposals in the coming months and continue to engage with Congress, who ultimately sets government spending levels. 2. USAID and State Department reorganization As part of the Trump Administration’s plans to streamline and reshape the federal government, it has announced plans to reorganize the State Department and USAID. USAID plays an important role in global health research and development (R&D), supporting late-stage clinical research and implementation research as well as operating Grand Challenges to identify and advance promising health innovations from around the world. USAID and the State Department submitted reorganization plans to the White House Office of Management and Budget on September 15, 2017, but details of those plans have not yet been made public and further information remains scarce. GHTC will continue to monitor evolving plans and policy and strongly advocate for continued leadership of USAID in global health innovation. 3. BARDA reauthorization The Pandemic and All-Hazards Preparedness Act (PAHPA), which authorizes the Biomedical Advanced Research and Development Authority (BARDA), is due for reauthorization this year by Congress. In recent years, BARDA has played an increasingly important role in the advanced development of medical countermeasures for emerging infectious diseases, like Ebola and Zika, and antimicrobial resistance. Reauthorization presents a potential opportunity to bolster BARDA’s role in the global health R&D space. GHTC will monitor the PAHPA reauthorization process and work with Congress to support a strengthened role for BARDA in the emerging infectious disease space. 4. Global health security GHTC is also watching US efforts to promote global health security, including continued support for the Global Health Security Agenda (GHSA)—an international partnership launched in 2014 to help countries strengthen their ability to respond to health threats. The United States is now funding GHSA through the one-time emergency Ebola supplemental funding, which expires in FY19, so future financing for the program remains uncertain. Without renewed commitment and financial support for global health security activities, the United States will have to pull back critical disease detection, prevention, and response operations around the world. GHTC will also work to include R&D in global health security policy decision-making. During the two most recent global disease epidemics, Ebola and Zika, a lack of proactive, sustainable funding for R&D meant that United States and the world did not have the drugs, diagnostics, and other tools needed to contain these diseases. Despite this, GHSA in its current form lacks any prioritization or commitment to R&D to detect, prevent, and respond to global epidemics. As domestic and global discussions on global health security continue, GHTC will advocate for R&D as a critical component of epidemic preparedness and response. 5. US engagement with key multilateral bodies Multilateral organizations and partnerships are vital mechanisms to help advance a healthier and more secure world. In our modern and increasingly globalized world, new, emerging, or long-standing health challenges, which do not respect borders, cannot be tackled by individual countries alone. Strong US leadership and funding for organizations like the United Nations (UN), the World Health Organization, and the Global Fund to Fight AIDS, Tuberculosis and Malaria are key to advancing global health and ensuring that these organizations function effectively in support of US priorities. Despite several senior Trump Administration officials expressing support for strong multilateral engagement, the United States’ role in pushing for a recent $285 million cut to the UN’s overall budget appears more indicative of how the United States can be expected to engage in the near future. While it is currently unclear exactly how these cuts will be implemented across the various UN health-related programs, GHTC anticipates significant impact on the various UN technical agencies’ ability to support global health, including R&D. GHTC is committed to leading strong, coordinated action to advance US leadership in global health R&D in 2018 and beyond. The United States has long been a leader in global health, development, and medical research, and we look forward to sustaining and bolstering this legacy in the years ahead.