Nationwide Consequences, Rural Devastation: The Unequal Toll of Public Health Spending Reductions.

This article examines the implications of recent and proposed reductions in federal public health funding, with a focus on how these cuts disproportionately impact rural and low-resource communities. Drawing insight from national datasets, the authors document the increasing reliance of state and local public health systems on federal funds, particularly in the aftermath of COVID-19. Scenario modeling reveals that a rollback to pre-COVID federal funding levels would likely leave many local jurisdictions unable to sustain core public health services, especially where local fiscal capacity is limited. The authors argue that, while some communities may be able to partially offset federal losses with local revenues, most lack the means to do so at scale-particularly rural areas already strained by limited infrastructure. This paper offers empirical estimates of federal support, evaluates the plausibility of local revenue substitution, and analyzes the consequences of federal disinvestment on the Foundational Public Health Services. These findings underscore a key tension in federalism in which calls for local autonomy amid shrinking federal support risk exacerbating health inequities and eroding core protections, both of which lead to critical questions about the federal government's role and responsibility in ensuring a resilient and equitable public health system.