Where Do We Go From Here? The Way Forward for State and Local Public Health

Introduction Our country’s governmental system of public health—including federal health agencies, state health departments, and local health departments—are navigating a sea change. The first half of 2025 has given way to numerous changes at the federal level and many others have been proposed for later this year. These include reductions in federal funding and the contraction and redesign—both in organization and purpose—of federal health agencies. These current and proposed changes will have a profound downstream impact on the state and local health departments as well as other partners that rely on federal funding and expertise. There are also major societal changes influencing our governmental public health system, at each level and collectively, such as change in public trust, the growing aging population, technological advancements, including artificial intelligence (AI), and Medicaid policy changes. These are just a few of the surrounding challenges and opportunities that will influence the public health department of the future. The purpose of this paper is to set the stage for future opportunities and support governmental public health, in particular, in continuing to provide the necessary resources for communities while reimagining structures for the future. Tenets for these structures include supporting state leadership to create stronger regional structures and fill national gaps, prioritizing core public health functions, diversifying funding, leveraging technological advancements, taking advantage of the national focus on chronic disease, and reassessing opportunities to support access. The Current Situation Funding: The first half of 2025 has been a challenging funding environment for the public health community. Beginning in March, as federal actions began to take shape, grantees including states and local health authorities, experienced termination of funding, delays in awards, and elimination of new grant opportunities. These actions resulted in layoffs and system wide contraction.1,2 One of the first funding decisions occurred around March 24th when states and some localities received notices abruptly terminating several funding streams from the US Centers for Disease Control and Prevention (CDC). The terminations were effective almost immediately. These dollars were initially approved by Congress to combat COVID-19, but they were also meant to strengthen public health infrastructure as a whole including the ability to detect and respond to infectious diseases like Mpox, H5N1, and Measles.1 For many states and localities, these funding cuts disrupted some of their core duties.3 Soon after, the FY26 President’s budget projected a dramatic decrease in funding across Health and Human Services (HHS), including the decimation of non-infectious disease programs at the CDC.4 Given that the majority of CDC funding supports state, local, territorial, and tribal (STLT) health departments, the threat of lost revenue supporting a myriad of public health functions loomed large.5 Currently, CDC distributes over 80% of appropriated dollars through external grants and contracts. The National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) alone is responsible for more than $800 million dollars in support to states and local communities.6 Similarly, CDC’s National Center for Injury Prevention (NCIP) grants more than 80% of its budget to partners across the country, with more than $600 million in a given year.7 According to NACCHO’s Profile of Local Health Departments, health departments get about 50% of their funding from the federal government.8 This department specific amount is highly variable and is affected by a number of factors, including a state’s public health structure. For example, Chicago and New Orleans get over 70% of their funding from the federal government often directly from agencies such as the CDC.9 Federal funding comes nearly equally through direct (25%) and federal pass-through (26%) grants, contracts, and cooperative agreements. Federal pass-through dollars come to local health departments via state government, making it hard to distinguish dollar sources at the local level.8 Furthermore, state health departments also receive over 50% of their public health funding from the CDC,10 so any cut to CDC funding greatly impacts states’ abilities to carry out public health duties, as well as that of their local and community-based partners. Threats to these dollars represented by late awards, paused or terminated awards, and restrictions resulting from Presidential Executive Orders, have and will continue to have a chilling impact on services ranging from diabetes prevention to violence prevention, as well as infectious disease prevention and outbreak and other emergency responses. In addition, the confusion caused by lack of communication, removal of subject matter experts, and disruptions to contracts that support work across the country has had a ripple effect on grantees and their subcontractors given their limited financial reserves. CDC reorganization For decades, CDC has been the preeminent national public health agency, and like many local and state public health offices, it has been organized around multiple centers and divisions. The prioritized focus has always been infectious disease, but centers dedicated to noninfectious diseases have grown since the mid-1900s when the noninfectious conditions replaced infectious diseases as the major causes of American deaths.11 Noninfectious causes of morbidity and mortality like heart disease, injuries, and diabetes are deeply impacted by the external nonmedical factors surrounding our communities and contributing to health outcomes seen today.12 The centers that address these conditions include NCCDPHP, NCIP, National Center on Birth Defects and Developmental Disabilities (NCBDDD), and the National Center for Environmental Health (NCEHS). They primarily focus on population-level prevention and health promotion interventions—not on individualized clinical treatment. For example, evidence-based interventions are preventing diabetes through systems changes like healthy food procurement, increasing physical activity through built environment changes that promote safe walking, preventing overdose through policy changes that support naloxone distribution, and preventing exposure to environmental hazards through regulatory actions. Policies and system changes have made an impact.13 In early spring, HHS Secretary Robert Kennedy Jr announced that 10 000 jobs would be eliminated across the department, and since February, there has been a steady flow of voluntary and involuntary departures. At CDC, between the deferred revenue program, early retirement and reduction in force, it is estimated that almost a quarter of the workforce will be or has already been removed.14 In addition, the administration announced a major reorganization of the Department of HHS with the proposed creation of the Administration for a Healthy America (AHA).15 The AHA will include elements of Health Resources Services Administration, Substance Abuse and Mental Health Services Administration, CDC, and the Office of the Assistant Secretary of Health. Many of the noninfectious programming from CDC are expected to move to AHA, but there continues to be confusion about other components such as those in NCCDPHP.15 In April, CDC NCCDPHP divisions were eliminated including The Division of Oral Health and the Office on Smoking and Health, along with the majority of the Division of Reproductive Health and Population Health. Significant components of the NCIP and the NCBDDD were also removed, with little information about what comes next for this critical public health work.16 In the FY’26 President’s Budget, proposed organizational cuts are even larger with many CDC programs being eliminated altogether including NCCDPHP and all of its programs.4 These changes mean that CDC’s public health expertise is being lost, leaving STLTs and the communities they serve without the subject matter expertise they had come to rely on from the federal agencies. The federal portion of our governmental public health system provides crucial functions that other parts of the system are not built to easily absorb, accommodate, or have the capacity to perform. For example, certain advanced laboratory functions, coordination of response across complex emergencies in multiple jurisdictions, and some of the most world-renowned expertise across many public health domains. And agencies historically ready for response may be understaffed and unavailable. It is important to note that not all changes and efficiencies at the federal level are “bad.” we need to continue to build and evolve a system to better promote and protect the public’s health that leverages every dollar invested in prevention. Similarly, the loss of federal centralized functions such as major national data systems will create a vacuum of information that state and local health departments depend on. Advisory groups like the Advisory Committee on Immunization Practices (ACIP)17 and the US Preventive Service Task Force18 are undergoing major changes, leaving states to consider their own strategies. With all of these organizational changes, the question of prevention looms large. What is the role of governmental public health in population-level prevention? Where does the work of prevention take place at the federal level? Who does it? What resources will be available, and how do population-based strategies amplify the current focus on individual decision-making? New HHS priorities and renewed national focus on chronic disease prevention Secretary Kennedy’s agenda includes a focus on reducing chronic diseases. This comes in the context of a broader grassroots movement to “Make America Healthy Again.” Major priorities of these efforts include removing food dyes and additives, reducing consumption of ultra processed foods, and decreasing exposure to environmental toxins. The Secretary has prioritized children and has also highlighted childhood conditions like Autism.19 FDA, NIH, and CMS are prioritizing lifestyle interventions and individual choice. For example, CMS innovation center recently published strategic direction focuses on a 3-pronged approach: promote evidence-based prevention, empower people to achieve their health goals, and drive choice and competition.20 The NIH and FDA recently announced an Innovative Joint Nutrition Regulatory Science Program as an element of Making America Healthy Again.21 The emergence of these priorities provides an opportunity for public health professionals to lift up evidence-based initiatives that intersect.22 However, the proposed elimination of the CDC NCCDPHP, the significant reductions in funding to public health departments, and the reorganization into AHA leaves the public health field in a quandary as to role and distinct contribution to the Secretary’s agenda. The US network of state and local health departments provides a ready workforce, uniquely outcomes-focused, with natural and long-time health authorities in place. These departments have existing influence and have demonstrated improvements in health and wellness of their communities across our country. Artificial intelligence Simultaneously, as federal directions are shifting, so is the reliance on information technology, particularly with the emergence of AI. Recently, the White House released America’s AI Action Plan23 and both FDA and HHS have appointed AI officers.24 AI has the potential to deeply change the practice of public health. Governmental public health has long relied on large surveys, reports on diseases, and local public health data to determine need and make decisions. Today, AI is seen as a critical tool to improve efficiency. However, the benefit to public health is still in its infancy. Early experiments demonstrate usefulness for community needs assessments, inspections, and clinical reporting.25 But without extensive prompts, review, and oversight, AI can make mistakes; mistakes which may have dire consequences for public health and communities. In addition, public health infrastructure has been eroded over time, and many health departments do not have skilled workers or financial resources to implement AI in daily work life. The field is facing the challenge of how best to use AI, when and where it is most helpful, what are the legal parameters for its use, and how quickly it can be implemented. Medicaid The One Big Beautiful Bill Act26 made profound changes to Medicaid policy that will take effect in coming years. These changes are projected to reduce Medicaid spending by $1T and the number of people insured by 10 million.27 Since Medicaid is a shared financial responsibility of states and the federal government, any reduction will represent significant financial pressure on state budgets. The unclear future of the 1115 waivers will also create a deficit for states that will affect multiple agencies and dramatically impact the safety net. For states that have used the waiver as a mechanism for expanding services such as those in the social determinants of health space, hard decisions will need to be made. Medicaid changes will also have numerous impacts on STLTs. Direct impacts include loss of clinical services and loss of revenue for reimbursable public health functions, eg, environmental lead testing for children on Medicaid. Other indirect impacts will be the downstream impacts to public health, eg, STD outbreaks due to lack of early screening. When dollars are short, clinical care generally becomes the major focus and population-based prevention efforts suffer. Where Do We Go From Here? This shifting landscape of funding cuts, federal reorganization, new HHS priorities and the MAHA movement, advancement of AI, and Medicaid policy changes creates an interesting and challenging backdrop in which to envision where health departments go from here. We provide a few suggestions on how health departments can navigate these new and shifting contexts in which they operate. Rebuild trust It is important to emphasize that the future of public health depends on rebuilding trust with the community. The pandemic had grave consequences for faith in public health. Conspiracy theories, misinformation, and alternative facts are rampant. Public health departments are working tirelessly to build trusting relationships with the communities they serve. They have a unique opportunity to continue this work through engagement, relationships, and transparent communication. In times of resource limitations, we often come together to achieve great things. Public health departments are well-positioned to amplify these efforts. Step in to fill national gaps With lack of federal funding and expertise and perhaps other tools and supports, STLTs can step in to fill gaps in national public health infrastructure or share resources in different ways. A new emerging area is enhanced partnerships among states and among localities and creating more regional efforts. For example, a team of epidemiologists can support multiple counties or laboratory services can be regionalized to support multiple states. Similarly, clinical guidelines, public communication assets, and data dashboards can also be shared across states or serve as a model that other states can use. In some cases, states have come together to make new vaccination recommendations, particularly in the face of changes to ACIP. STLTs could also identify respective strengths and provide this expertise and support to other STLTs. Strategies include, technical assistance in responding to wildfires or providing epi-aid type support in managing an outbreak. There are now many examples of new partnerships forming to identify gaps, build on shared services, and develop collaborative models in ways we could not imagine in the past. Attend to core functions To meet an unstable future head on, STLTs will need to first and foremost understand what the community needs and wants. What issues do they expect their health department to focus on? What services must public health deliver? Public health departments will need to retreat to “core” or essential public health activities that mirror the 10 essential public health functions21 and include regulatory health authorities, response and data These functions are critical to and often for via local or state They are the elements of public health and services to the But there will always be emerging and issues that When emergencies of the public health departments Local and state public health departments have a of out how to respond from the to This ability to meet is an important that must funding To meet emerging as well as current revenue will be Current state and local to public health across and leaving some more than for resources include local and national For example, in some jurisdictions, local have come together in a to support local public In other new be an and while others of departments to achieve and We expect to renewed efforts in these In addition, the of for clinical services, prevention services, and community health workers be The of the community care model by services is and can public health programming to Medicaid and diversifying funding is it may in the current environment of decreasing federal According to the National of major impacts will continue to on including state, and local health and local will have increasing responsibility for of services is an and for new work In addition, the for new revenue strategies like at the local will across the as will both existing and potential Public health departments will need to and work with their and communities to determine where to direct their advancements, eg, AI to support will be challenge that will With the loss of federal data and will to the states and local The use of current data systems may be and alternative strategies AI tools could like clinical and local can be in and Similarly, with AI and of efficiencies could to the these tools may be way of more with new partnerships With the elimination of federal example, the Advisory Committee on in and national or may have to a and may need to a role in creating or Public health may need to create for and across and among other partners. of Public Health and will also be critical particularly in to and The between public health and health care has been long but often These relationships will even more important and on and of population-based prevention efforts will support and of the new partnerships will also be At the local in the and can fill in gaps and address emerging The are many and from to to food and may mean that public health a role than a leadership Many public health departments have been and their role as the Public Health for their community. 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