This could hurt. Carlos Osorio/AP Photo

The ACA directed millions of dollars to urban public health initiatives addressing everything from lead poisoning to healthcare access.

Every year, about 300 children under age 6 turn up with elevated blood-lead levels among the thousands of lab tests surveilled by Houston’s Childhood Lead Poisoning Prevention program. In the vast majority of cases, their staff follows up.

Health officers reach out to parents to ensure that their kids are receiving care. Lead inspectors visit the aging homes in which those kids often live, and remediation crews scrape and replace the toxic paint from window frames and siding. Educators knit themselves into communities, educating schools, churches, PTA groups, and organizations devoted to incoming refugees.

To pay for many of these tasks, the city of Houston relies on about $300,000 in direct annual funding from the Centers for Disease Control and Prevention. The CDC receives that money from the $1 billion Prevention and Public Health Fund, which is part of the Affordable Care Act. If the ACA is repealed—which it could be, if Republicans in Congress get their way—the Prevention Fund could be eliminated along with it.

That could mean vanishing resources for programs like this, and many others around the country. It’s not just Houston, or Flint; thousands of American communities have off-the-charts blood-lead levels. “We make sure our children aren’t getting poisoned,” says Kaavya Domakonda, Houston’s lead poisoning prevention program manager. “It would be hugely detrimental if those funds went away.”

Most news coverage of the Republican crusade to eliminate ”Obamacare” has focused, rightly, on the 20 million Americans who stand to lose coverage if the signature components of the ACA were torn down. Those include the expansion of Medicaid, new coverage offered through the Health Insurance Marketplace, and changes in private insurance pertaining to young adults and people with pre-existing health conditions.

But those changes to the health insurance marketplace weren’t all that the ACA achieved. It also established the nation’s first mandatory dollar-stream devoted to improving public health: the Prevention and Public Health Fund. “You can feel it,” says Richard Hamburg, the executive vice president and COO at the Trust for America's Health, a nonpartisan organization that advocates for disease prevention. “That fund has led to actual programs that are impacting people at the local level.”

These are meaningful fixes to health and environmental concerns that shape daily life in towns and cities. According estimates cited by the American Public Health Association, every 10 percent funding increase for community-based public health programs can reduce preventable deaths by 1 to 7 percent.

The PPHF works to “improve health outcomes, and to enhance health care quality,” primarily by funding about 12 percent of the CDC’s annual budget, or roughly $890 million. The CDC passes those dollars on to state, municipal, and community-run programs that respond to a host of public health issues. (An additional $40 million of PPHF funds go to the Administration for Community Living and the Substance Abuse and Mental Health Services Administration.)

Houston is one of six cities that gets direct funds from PPHF for its childhood lead poisoning prevention program. Los Angeles, Washington, D.C., Chicago, New York, and Philadelphia have also received millions of dollars to monitor lead poisoning risks, educate communities, and keep tabs on children’s treatment. (All of these cities are approaching the end of a three-year grant.) With those PPHF dollars, the CDC also funds state-backed anti-lead programs; it spent $13 million on lead prevention programs nationwide in 2016.

What else does the PPHF provide for, through the CDC? Last year, $40 million bolstered the CDC’s Epidemiology and Laboratory Capacity program, which enhances the ability of state and local labs to respond to infectious disease outbreaks. More than 25 percent of total ELC grants went to Zika research, in all 50 states and a number of cities. The CDC distributed another $160 million of PPHF dollars to Preventive Health and Health Services Block Grants, a monumental program that supports tailor-made health solutions in states and local communities. A few examples: In recent years those funds have allowed California to expand its health alert network, which notified statewide hospitals to local outbreaks during the 2014 Ebola outbreak; Fairfield, Connecticut rolled out its first bike route, and Allen County, Kansas used its block grant to set up a network of farmers markets; in New Mexico, students formed and sustained an exercise club in a pueblo.

Money from the PPHF has also kept a remarkable program called Racial and Ethnic Approaches to Community Health (REACH) afloat. The CDC distributes nearly $51 million to 49 “REACH” partners in communities around the country, which help connect minority communities with high health risk factors to care and prevention services. Example: In the southwest Bronx—the poorest urban county in the U.S., where residents are more than five times likelier to die of diabetes than those in wealthy New York neighborhoods—the local REACH branch runs workshops in local churches on how diabetic congregants can control their condition, advocate for their health, and access better medical information.

That’s just one of the many programs it runs, across the 280,000 Bronx County residents it serves. Other, earlier REACH programs show results: From 2001 to 2009, pneumonia vaccination rates in REACH grantee communities areas rose 10 percent among blacks, from 12.5 percent among Latinos, 22 percent among Alaskan/Pacific Islanders, and 11 percent among Native Americans.

These are still only a fraction of the programs, services, and research funded by the PPHF. All told, states would lose more than $3 billion over the next five years from grants and programs supported by the fund, according to a recent analysis by the Trust for America’s Health. That means every major city stands to see millions of dollars, and life-giving programs, go away. So do small towns and rural places.

Congress could choose to continue to fund any these community-based programs in the absence of the ACA. Many of them, including the REACH program and lead poisoning prevention services, were around prior to the ACA, supported by various discretionary funds that were generally passed on to states first. But even if Congress decides it liked to keep one program funded or another, it won’t have the same dedicated funding stream—which, by the way, is set to double by 2022—to do it. It would have to take cash from other agencies, like the departments of Labor, Education, or Health and Human Services, and leave holes in their budgets.

Several GOP leaders and the president-elect have promised a comprehensive healthcare plan to fill the vacuum created by an ACA repeal, but no concrete ideas have been offered. For now, no one can say what the full implications for health coverage, and public health, will be. “Without the Prevention Fund in place, will the federal government figure out how to make up for it?” asks Hamburg. “Until anyone tells us, we have to assume it won’t be available.”

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