In this March 23, 2020, file photo, Maine CDC Director Nirav Shah gives a COVID-19 press briefing in Augusta inside the Maine Emergency Management Agency alongside interpreter Regan Thibodeau. Credit: Troy R. Bennett / BDN

Public health spending is at a 10-year high in Maine after it and the rest of the country scrambled to respond to the COVID-19 pandemic in 2020. Those who depend on it fear any retrenchment would set back any response to the next pandemic.

States have seen billions of dollars in federal aid to fight the pandemic over the last two years. But Congress’ willingness to continue to spend on the pandemic is uncertain after Republicans balked at recent proposals, which could lead to a reduced federal response.

That is a problem that public health agencies have faced for years. In the decade ahead of 2020, state spending on public health dropped by 18 percent, according to an Associated Press and Kaiser Health News analysis. It left many agencies less prepared for the pandemic.

Maine was among those catching up. When Gov. Janet Mills took office in 2019, her administration moved to fill dozens of Maine Center for Disease Control and Prevention positions left empty by former Republican Gov. Paul LePage, raising the workforce from 174 to 230 by the time the pandemic began. Federal funding has helped grow the ranks to more than 300.

But public health is more than its emergencies, experts warn. They say the boom-and-bust nature of crisis spending can leave out the everyday services that make a population more resilient and that the state and federal governments should continue to focus on preventing COVID-19 and improving other services.

The cyclical nature of public health spending can affect the ability to respond in emergency and undermine services like immunizations, parental support and tobacco tobacco cessation programs, said John Gale, the president of the National Rural Health Association and a University of Southern Maine researcher. He likened it to house flipping.

“They do a lot of surface stuff, but they don’t necessarily fix the foundation,” he said.

Records of spending on the Maine CDC dating back to 2010 showed that state funding hit a low point during that period in 2017 at $6.4 million. That was after LePage and lawmakers cut back certain positions in state budgets and declined to fill vacancies. For example, the LePage administration resisted hiring public health nurses even after a law compelled it.

State spending increased by 33 percent by 2020 when Mills took office and the state has appropriated $24 million for next year. That has been supplemented by millions in federal spending, which rose from $48 million in 2020 to $110 million for this year so far.

Mills made it a priority to rebuild the CDC, agency spokesperson Robert Long said. That allowed the agency to boost its planning for emergencies and hire staff with public health expertise. Democrats have highlighted that point in early pro-Mills campaigning in her race against LePage this year.

LePage was often critical of the Department of Health and Human Services’ budget, which the CDC is housed under, particularly funding for Medicaid and welfare.

In 2015, his health commissioner, Mary Mayhew argued while proposing to cut a tobacco prevention program funded through a settlement that state dollars must be prioritized and must be “evaluated for effectiveness.” Funds for that program were often repurposed to plug budget gaps.

The state’s reliance on one-time federal funding is a “long-term fiscal disaster” for the state, LePage campaign spokesperson Brent Littlefield said. The former governor “is not looking to repeal anything that is good for Maine people” and will “guarantee that all of our investments, like public health, are managed in a way that ensures the ability for us to fiscally maintain those programs into the future.”

The big boost in funding was geared toward COVID-19 prevention such as moving protective gear, contact tracing and the state’s vaccination effort, Long said. But it also made sure other services, like health inspections, lead poisoning prevention and tobacco cessation, could continue as they became more expensive and complicated.

The federal funding has been crucial to making sure the state has a ready supply of vaccines and therapeutics, Long said. If that diminishes or the state cuts back on funding, it could make those services more expensive and harder to get.

While federal funding has been helpful in mitigating the cost of the pandemic, it has not necessarily bolstered other public health services, said Tina Pettingill, the deputy director of Portland’s health and human services department.

The city is one of the few in the state that provides public health programming. That includes a sexually transmitted disease clinic and primary, maternal and child health care for minority communities and obesity prevention, mostly with state and federal dollars and grant funding.

The city received American Rescue Plan Act money that allows it to begin building up infrastructure it previously lacked. It is looking to hire an immunization coordinator to focus on influenza and public school-required vaccines, as well as COVID-19 shots.

But that money will go away eventually, which makes the future of those efforts uncertain. Even if the pandemic is not as heightened as it was, people are still vulnerable and dying from the illness, Pettingill said. The need to provide services for it will continue until it does, she said.

“That’s what we are constantly doing in public health,” she said. “You get something that is needed and necessary, but it’s on a timeline.”