What Trump winning the election could mean for the CDC

State and local health departments would no longer be able to track opioid overdoses, provide cancer screenings and help people quit smoking, according to health officials, if Republicans carry out their plans to dramatically shrink the Centers for Disease Control and Prevention under a second Donald Trump presidency.

Conservatives in Congress and Washington think tanks have proposed eliminating programs they say are not central to fighting infectious disease. Republican House appropriators want to slash the public health agency’s budget by about 20 percent and eliminate two dozen programs they consider “duplicative and controversial,” including initiatives to study the public health impact of climate change.

Key advisers in the Trump administration had discussed narrowing the CDC’s mission in the early months of the coronavirus pandemic in 2020. Since then, Republican scrutiny has sharpened, with lawmakers and other policy experts voicing growing support to downsize the agency’s scope.

“Many of the things within CDC really don’t belong there,” said Joel Zinberg, a former health policy adviser in the Trump administration who coauthored a policy paper last year with Drew Keyes, senior policy adviser to House Speaker Mike Johnson (R-Louisiana), for the Paragon Health Institute, a conservative think tank.

The CDC was founded in 1946 to fight malaria, but over the decades, “diverse and fashionable concerns” such as environmental justice and health equity have crept into the agency’s portfolio, Zinberg said. Those programs should be moved to other agencies, he said, so the CDC can focus solely on preparing for the next pandemic.

Scott Gottlieb, former commissioner of the Food and Drug Administration under Trump, has sounded this theme repeatedly. In his most recent essay published this month in JAMA Health Forum, he wrote that transferring some CDC responsibilities, such as its annual survey of middle and high school students about tobacco use, to the FDA, which regulates tobacco products, could help the CDC gain more money and authority.

“The only way to properly resource the core functions of CDC is to get a broader political compromise around the scope of the agency’s mission,” Gottlieb said in an interview.

But the proposals to refocus the agency have prompted an unusual outcry from eight former CDC directors who served in Democratic and Republican administrations. They warned in a recent letter that restricting CDC’s efforts to only infectious diseases would cost lives and damage the economy. The agency’s tobacco control program, for example, protects millions of people from addiction and cuts the need for expensive smoking-related medical care for lung disease, cancer, strokes and heart attacks, they said.

“Limiting our health defense to just some threats would be like allowing our military to protect us from only some types of attack, telling the National Weather Service to warn people about tornadoes but not hurricanes, or allowing doctors to treat only some diseases,” the former directors wrote in the Sept. 5 letter to the editor published in STAT.

Signatories include Rochelle Walensky, who served under President Joe Biden; Robert Redfield, who served under Trump; and Tom Frieden, who served under Barack Obama.

Congressional Republicans have succeeded in limiting the CDC’s focus in the past. In 1996, lawmakers forbade CDC funding from being used to advocate for gun control, effectively halting research on gun violence for two decades.

It’s unclear which GOP proposals to restructure CDC will be implemented. Some Republican lawmakers have voiced support for the agency’s work, especially on overdoses, maternal health and mental health. GOP House appropriators have proposed more money to combat emerging and zoonotic infectious diseases. Final budget decisions won’t be made until after the Nov. 5 election.

Vice President Kamala Harris has not spoken about the CDC as she’s campaigned for the presidency, and her campaign did not respond on the record to a request for comment.

By law, the Health and Human Services secretary has the power to cut CDC staffing and priorities - without congressional approval. If Trump wins another presidency, his HHS secretary could unilaterally reorganize the agency even if Republicans don’t recapture control of the House and Senate.

“If you have a split Congress and you can’t get bipartisan agreement on what to do, then you’ll be falling back on administrative tools to do it,” Zinberg said. “And I suspect there’ll be some movement in that direction.”

The HHS secretary could “simply back burner a lot of programs on chronic disease, injury and violence because they may not be consistent with a germ-focused agency,” said Jason Schwartz, a Yale School of Public Health professor who studies the work of government health agencies.

Trump has rarely mentioned the CDC on the campaign trail. But his recent embrace of Robert F. Kennedy Jr.’s call to address the country’s “chronic disease crisis” appears to be at odds with conservatives calling for an infectious-disease-only CDC. Many CDC programs address heart disease, cancer, diabetes and other chronic illnesses that are among the leading causes of death in the United States.

Some public health advocates and former Trump aides expressed skepticism that Trump would follow through on Kennedy’s “Make America Healthy Again” (MAHA) agenda, given Trump’s uneven track record of delivering on campaign promises.

“The concern is that chaos would reign because you don’t know how it will end up between the more traditional conservatives and the more fringe groups like Bobby’s,” said one public health official, referring to Kennedy, the founder of a prominent anti-vaccine group. The person spoke on the condition of anonymity for fear of antagonizing GOP officials who would control health policy if Trump wins another presidency.

Danielle Alvarez, senior adviser for the Trump campaign, said in a statement to The Washington Post before Trump and Kennedy teamed up on MAHA that the campaign has “made it clear that only President Trump and the campaign, and NOT any other organization or former staff, represent policies for a second term.”

The Trump campaign would not provide additional comment about the incongruity of conservative efforts to reorganize CDC around communicable diseases and Trump’s sudden alignment with Kennedy’s emphasis on chronic illnesses.

A person close to the Trump campaign said the chronic disease focus represents a shift for the campaign. The CDC will play an essential role, the person said, speaking on the condition of anonymity because they were not authorized to speak on the record.

“We see CDC completely involved in childhood obesity. We see CDC completely involved in childhood diabetes. We see CDC completely involved in every single thing that we’re talking about to kick off in the first 100 days on childhood chronic disease,” the person said.

Slashing the CDC budget or narrowing its focus has not been a top priority in campaign discussions, the person said, adding that earlier intervention and treatment of chronic disease could result in cost savings.

Redfield, Trump’s former CDC director, has endorsed Kennedy as the “right man for the job” to address chronic childhood disease in an op-ed published last month in Newsweek.

Zinberg and other conservatives say they welcome the emphasis on chronic ailments. But such work is better handled by other federal agencies, such as the National Institutes of Health - not the CDC, Zinberg said.

Project 2025, a right-wing policy operation that includes several former members of the Trump administration, has proposed splitting the CDC into two entities. While the section on the CDC in the 900-page book does not address chronic disease, Roger Severino, the lead author of the health chapter and a former Trump administration official, said in an interview that a restructured CDC would still address chronic illness. “That should cover a range of issues beyond just infectious diseases,” Severino said.

Project 2025 wants to remove conflicts of interests from the CDC by separating its scientific function - collecting data on infectious-disease outbreaks - from a policymaking entity that would oversee very limited public health recommendations. For example, CDC officials would be barred from making recommendations about masking or vaccinations for schoolchildren under Project 2025′s proposals; those decisions would instead be left to parents and medical providers.

Severino said the document was formulated independently of the Trump campaign. There have been no discussions with the campaign about implementing its ideas in a potential second term, he said.

Trump has repeatedly distanced himself from Project 2025.

State and local health departments would feel the biggest impact of any narrowing of the CDC’s scope or mission. They rely on the agency not only for funding - many depend on the CDC for up to 90 percent of their budget - but technical expertise.

“If CDC, all of a sudden, was dismantled, that would wreak havoc on the front lines of public health,” said Anand Parekh, a physician and chief medical adviser at the Bipartisan Policy Center, a centrist think tank.

In Connecticut, a CDC grant funds a health department staffer who works with the state medical examiner to track where opioid deaths are occurring. Knowing people are dying in their homes means health officials can distribute Narcan, the lifesaving nasal spray that reverses opioid overdoses, to family members, said Manisha Juthani, a physician who heads Connecticut’s public health department.

“That kind of work has helped us turn the curve on opioid deaths,” she said. She does not know how the program would continue if the CDC’s mission is narrowed.

In Mecklenburg County, North Carolina, Raynard Washington said his health department relies on the federal agency to fund breast and cervical cancer screening. If Republicans have their way, “we wouldn’t be able to offer mammograms to hundreds of women, especially those adults who don’t have insurance,” said Washington, the county health department’s director.

The Kansas City, Missouri, health department relies on the CDC to help pay for a youth violence prevention program. Hospitals contact the health department when they have patients who are gunshot victims to help them find jobs or resources to complete a high school equivalency degree, among other social services.

Conservative experts say these programs could be funded by other health agencies so as not to distract from the CDC’s core purpose.

The agency’s portfolio has broadened over time from an infectious-disease focus to include a wider range of health issues as the leading causes of death have shifted.

In the past year, the Atlanta-based agency has responded to a growing number of measles cases, an international health emergency of mpox, a bird flu outbreak in dairy cows, lead in apple sauce, a train derailment in East Palestine, Ohio, and a listeria outbreak at a Boar’s Head plant in southern Virginia.

CDC Director Mandy Cohen, in a recent meeting with journalists in Wellesley, Massachusetts, reiterated that health threats “are not confined to infectious disease.”

“The things that kill people under the age of 50 are unintentional injuries - suicide, overdose, drowning, car accidents,” Cohen said.

In their letter to the editor, the former CDC directors said that when a health threat occurs, scientists often don’t know right away whether it is infectious or toxic or a false alarm or a new disease, they wrote. Figuring that out requires experts with a wide range of expertise.

During the Zika epidemic in 2016, scientists learned for the first time that a mosquito-borne virus caused a rare birth defect and other severe fetal abnormalities. The CDC response included experts in reproductive health, virology, child development, mosquito control and environmental health.

Brenda Fitzgerald, an OB/GYN, was head of the Georgia health department, at the time.

“Who knew this huge increase in babies born with these huge neurological problems was caused by a mosquito?” said Fitzgerald, who went on to serve as CDC director under Trump in 2017 and who signed the Sept. 5 letter. “When you’re trying to figure out a health risk, it may not be as straightforward and well defined.”

Jenna Portnoy and Clara Ence Morse contributed to this report.