Investing in America's Health

A State-By-State Look At Public Health Funding And Key Health Facts

March 2012

Investing in disease prevention is the most effective, common-sense way to improve health. It can help spare millions of Americans from developing preventable illnesses, reduce health care costs, and improve the productivity of the American workforce so we can be competitive with the rest of the world.

Tens of millions of Americans are currently suffering from preventable diseases such as cancer, heart disease, and diabetes.  And, today's children are in danger of becoming the first generation in American history to live shorter, less healthy lives than their parents.

For eight years, the Robert Wood Johnson Foundation has supported the Trust for America's Health in releasing an annual Investing in America's Health report to examine public health funding and key health facts in states around the country. 

Where you live should not determine how healthy you are.  But, we've found that disease rates vary dramatically from city to city and region to region - and funding for public health and disease prevention programs also vary dramatically from neighborhood to neighborhood, community to community, city to city and state to state.

The nation's public health system is responsible for improving the health of Americans.  But, the public health system has been chronically underfunded for decades.  Analyses from the Institute of Medicine (IOM), The New York Academy of Medicine (NYAM), the U.S. Centers for Disease Control and Prevention (CDC), and a range of other experts have found that federal, state, and local public health departments have been hampered due to limited funds and have not been able to adequately carry out many core functions.

In our analysis, we found that federal funding for public health has remained at a relatively flat and insufficient level for years. The budget for CDC has decreased from a high of $6.62 billion in 2005 to $6.32 billion in 2011. 

At the state and local levels, public health budgets have been cut at drastic rates in recent years.  According to a TFAH analysis, 40 states decreased their public health budgets from FY 2009-10 to FY 2010-11, 30 states decreased budgets for a second year in a row and 15 for three years in a row.  In FY 2010-11, the median state funding for public health was $30.09 per capita, ranging from a high of $154.80 in Hawaii to a low of $3.45 in Nevada.  From FY 2008 to FY 2011, the median per capita state spending decreased from $33.71 to $30.09.  A recent study conducted by the National Association of County and City Health Officials (NACCHO) found significant cuts to programs, workforce and budgets at local health departments (LHDs) around the country. Since 2008, LHDs have lost a total of 34,400 jobs due to layoffs and attrition. Combined state and local public health job losses total 49,310 since 2008. LHDs continue to struggle with budget cuts.  In July, 2011 nearly half of LHDs reported reduced budgets, which is in addition to 44 percent that reported lower budgets in November 2010. In addition, more than 50 percent of LHDs expect cuts to their budgets in the upcoming fiscal year.

• DIFFERENCES IN FEDERAL FUNDING FOR STATES:  Federal public health spending through CDC averaged out to only $20.28 per person in FY 2011.  And the amount of federal funding spent to prevent disease and improve health in communities ranged significantly from state to state, with a per capita low of $14.20 in Ohio to a high of $51.98 in Alaska. 
• DIFFERENCES IN STATE FUNDING:  This report also examined state funding and found that the median amount in state fiscal years 2010-2011 for public health equaled only $29.80 per person, ranging from a low of $3.45 per person in Nevada to a high of $154.80per person in Hawaii.  Regionally there were large differences in state funding. 
• DIFFERENCES IN HEALTH STATISTICS BY STATE:  The report finds major differences in disease rates and other health factors in states around the country.  For instance, only 5.6 percent of residents of Massachusetts are uninsured compared to almost 25 percent in Texas, and less than 10 percent of adults in Utah are current smokers while almost 27 percent report smoking in West Virginia.

There is little strategic rationale for the differences in funding – and therefore, for the way public health is funded in America.  The federal funds are a mixture of population-based formula grant programs, incidence or prevalence based formulas, and a series of competitive grants – where some states receive funding and others do not, Because of insufficient funding for the CDC, many states submit competitive grants (“approved but unfunded” applications) that cannot be awarded.  But in most cases, there is no officially defined mode or coordination for targeting or strategically focusing the funds.  State and local funding varies dramatically based on the structure of a state’s public health department.  Some departments are centralized, while others are decentralized where responsibilities rest more on local departments than at the state level.  However, states and localities also place different priorities on public health, which also accounts for differences in the funding.  These state-by-state comparisons do not include county or city revenues that are generated to support local health departments, which are also quite variable.

Recommendations

America’s future economic well-being is inextricably tied to our health.  High rates of preventable diseases are one of the biggest drivers of health care costs in the country.  And, right now, Americans are not as healthy and productive as they could be or should be to compete in the global economy.

In tough economic times, it is more important than ever to invest in the health of Americans.  Improving the health of Americans is essential for reducing health care costs and increasing our productivity – to help get the economy back on track for the long term. 

The nation’s public health system is responsible for keeping Americans healthy and safe.  Public health is devoted to preventing disease and injury.  If we successfully kept Americans healthier, we could significantly improve health, drive down trips to the doctor’s office, and reduce health care costs. 

In addition to shoring up the core ongoing funds for public health, we need to ensure the new Prevention Fund is used to build upon and expand existing efforts, not supplant.  If we do not keep the foundation of support intact, we will never advance in the fight to prevent diseases, curb the obesity epidemic, or reduce smoking rates. 

The report recommends that:

1. Core funding for public health – at the federal, state and local levels – be increased; 
2. Funding be considered strategically – so funds are used efficiently to maximize effectiveness in lowering disease rates and improving health;
3. The Prevention Fund be targeted to effectively and efficiently reduce rates of disease by focusing on efforts that help to modernize our approach to public health – from investing more in locally-determined, evidence-based prevention activities to strengthening the core capacity of health departments to operate in a reforming and technologically advanced health care system; and
4. Accountability must be a cornerstone of public health funding –the use of funds and the outcomes achieved from the use of the funds should be transparent and clearly communicated with the public.