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 responsibilities, health authorities, response activities, and data reporting. These functions are critical to perform and often paid for via local or state dollars. They are the key elements of public health accreditation and guarantee services to the public. But there will always be emerging and urgent issues that require response. When emergencies hit, regardless of the cause, public health departments respond. Local and state public health departments have a history of figuring out how to respond from the opioid epidemic to H1N1. This ability to meet demand is an important asset that must continue. Diversify funding To meet emerging demands as well as sustain current activities, creative revenue generation will be critical. Current state and local contributions to public health vary wildly across topics and geographies, leaving some jurisdictions much more vulnerable than others. Opportunities for resources include local and national foundations. For example, in some jurisdictions, local foundations have come together in a unified approach to support local public health. 28 In other communities, new taxation might be an option (sugar taxes and tobacco taxes), while others might choose creative consolidation of departments to help achieve efficiency and cost-saving. We expect to see renewed efforts in these directions. In addition, the exploration of reimbursement for clinical services, prevention services, and community health workers should be explored. The evolution of the community care hub model largely led by human services is gaining popularity and can incorporate public health programming leading to possible Medicaid and Medicare reimbursement. 29 While diversifying funding is critical, it may prove increasingly difficult in the current environment of decreasing federal funds. According to the National Association of Counties, major impacts will continue to put strain on intergovernmental relations including federal, state, and local health entities. States and local governments will have increasing responsibility for non-federal cost sharing of services (SNAP is an example) plus added administrative burden and costs for new regulations (Medicaid work requirements). 30 In addition, the appetite for new revenue strategies like taxes, at the local level, will vary across the nation as will both existing and potential resources. Public health departments will need to prioritize and work with their elected officials and communities to determine where to direct their attention. Identify technology advancements, eg, AI to support surveillance Data will be another challenge that will require partnerships. With the loss of federal consolidated data, data collection and analysis will likely fall to the states and local jurisdictions. The use of current data collection systems may be curtailed and alternative strategies using AI tools could prove helpful. Partners like clinical delivery systems, universities, and local non-profits can be helpful in collecting and analyzing data. Similarly, familiarity with AI and identification of cost-saving efficiencies could prove incredibly helpful to the field. Developing these tools may be one way of doing more with less. Create new partnerships With the elimination of various federal coordinating entities—for example, the Advisory Committee on Heritable Disorders in Newborns and Children—other national organizations or entities may have to play a convening and consensus-building function. Medical associations may need to play a greater role in creating guidelines or recommendations. Public health associations may need to create avenues for convening and consensus building across STLT and among other partners. Schools of Public Health and Medicine will also be critical partners, particularly in helping to gather and analyze data. The relationship between public health and health care has been long term but often complicated. These relationships will likely become even more important and complementary. Data sharing, collaboration on interventions, and sustainability of population-based prevention efforts will require mutual support and redrawing of "turf. " But, beyond the likely candidates, new partnerships will also be required. At the local level, multi-sector organizations in the non-profit and for-profit sectors can help fill in gaps and address emerging issues. The candidates are many and range from economic development to transportation to food purveyors. Defining roles and minimizing redundancy may mean that public health plays a collaborating role rather than a leadership role. Many public health departments have been building and establishing their role as the Chief Public Health Strategist for their community. They have honed their leadership skills over time and regularly convene community partners to achieve the best results, working in tandem together and leveraging one another's best assets and strengths. In times of stress, working across programs, with multiple partners, resting on existing infrastructure has been a key attribute of public health departments. At this moment, coalition building with combined resources will be needed, and public/private strategies to address critical issues should be part of the solution. With a diminishing federal role and support for public health, the relationship within our governmental health system among state and local health entities will need to be bolstered and improved as well. Changing responsibilities, capabilities, capacity, and funding will require state and local health departments to work in new ways to execute on their promise to protect the wellness and safety of their jurisdictions and to determine what is possible together. Recommit to demonstrating the return of the investment in prevention Studies have been performed over the decades on the importance of investing in the prevention of illness and the return it provides in terms of human lives saved, morbidity and chronic disease avoided, life expectancy improved, and so on. 13, 31 Other public health studies have clearly demonstrated the cost of a single measles case in a community (it is estimated at 32 000 per case) and the average cost of an outbreak (estimated at 152 000 per outbreak). 32 To prepare for our public health priority argument, we need to be equipped to address impact, cost, and savings (human, financial, capital, labor, economic, and otherwise) in a myriad of different ways to different audiences including impact to self, family, friends, businesses, governments/officials, schools, society, etc. Our field must continue to update, improve, and simplify its own messaging on the value of public health to people and to our own government. New opportunities to address chronic disease With any significant change, opportunities arise. The enhanced focus on wellness is shaping the environment in and outside of government. CMS and NIH are incorporating lifestyle fitness coaching, focusing on ultra processed foods, and examining environmental contributions to chronic conditions. 21 Physical activity opportunities will be a priority, in schools, workplaces, and communities especially given the new focus on the Presidential physical fitness test. 33 Public health has an opportunity to take the lead as a communication channel on all of these subjects and reacquaint the public and new partners with tools already in the belt—from food procurement guidelines to built environment principals to how best to work with our families, schools, and children. Questions on the value of nutritional supplements and ingredients abound, and assisting constituents with their health literacy is becoming more imperative. The public health system is an incredible national asset; public health staff know their communities, they have inroads with community organizations, and understand strategies for connecting with vulnerable populations. Support health care in new ways The role of public health in health care access could amplify as Medicaid resources diminish. There are opportunities to strengthen relationships with health centers, particularly the federally qualified health centers who deliver primary care. Public health needs to re-assess the role it will play in ensuring health care access to all populations and creating new partnerships with the health system. For example, health departments can partner on community benefits approaches, establishing maternal levels of care, health systems level prevention work, or delivering care in new ways. There is new attention being paid to primary care along with new models such as direct primary care. 34 The recently released rural health transformation grants, which will only replace a fraction of the funding lost through Medicaid revenue, nonetheless can provide an avenue to envision new forms of collaboration between public health and health systems. Health departments can lean into their epidemiologic expertise to monitor population health access and utilization, coupling this data with health behavior data. These will require new partnerships with providers and patients. Public health and primary care have a great deal in common and a responsibility to ensure access to quality services. Conclusion Today, public health departments are facing critical challenges and decisions. Navigating these turbulent waters will be critical for the future sustainability of the field. But governmental public health and community partners have always been resilient, weathering the storms of change. Our knowledge of communities, partnerships, and our ability to engage, respond, and elevate new and emerging issues is foundational. Communicating what and how we do it in a more visible manner at the ground level and creating new partnerships will be key. Where we go from here is up—the public's health depends on it.
Hacker et al. (Tue,) studied this question.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: