Not Only How Much But How: The Importance Of Diversifying Funding Streams In A Reimagined Public Health System.

Revenue diversification may be a synergistic strategy for transforming public health, yet few national or trend data are available. This study quantified and identified patterns in revenue diversification in public health before and during the COVID-19 pandemic. We used National Association of County and City Health Officials' National Profile of Local Health Departments study data for 2013, 2016, 2019, and 2022 to calculate a yearly diversification index for local health departments. Respondents' revenue portfolios changed fairly little between 2016 and 2022. Compared with less-diversified local health departments, well-diversified departments reported a balanced portfolio with local, state, federal, and clinical sources of revenue and higher per capita revenues. Less-diversified local health departments relied heavily on local sources and saw lower revenues. The COVID-19 period exacerbated these differences, with less-diversified departments seeing little revenue growth from 2019 to 2022. Revenue portfolios are an underexamined aspect of the public health system, and this study suggests that some organizations may be under financial strain by not having diverse revenue portfolios. Practitioners have ways of enhancing diversification, and policy attention is needed to incentivize and support revenue diversification to enhance the financial resilience and sustainability of local health departments.

Contemporary Public Health Finance: Varied Definitions, Patterns, and Implications.

The financing of public health systems and services relies on a complex and fragmented web of partners and funding priorities. Both underfunding and "dys-funding" contribute to preventable mortality, increases in disease frequency and severity, and hindered social and economic growth. These issues were both illuminated and magnified by the COVID-19 pandemic and associated responses. Further complicating issues is the difficulty in constructing adequate estimates of current public health resources and necessary resources. Each of these challenges inhibits the delivery of necessary services, leads to inequitable access and resourcing, contributes to resource volatility, and presents other deleterious outcomes. However, actions may be taken to defragment complex funding paradigms toward more flexible spending, to modernize and standardize data systems, and to assure equitable and sustainable public health investments.

Associations between physician practice models and health information exchange.

OBJECTIVES: The interaction between emerging physician practice models and the use of health information exchange (HIE) remains understudied. We examined associations between the use of emerging practice models and the use of HIE. We also examined barriers to HIE adoption among physicians who were not utilizing HIE. STUDY DESIGN: Survey data came from a 2019-2021 statewide census of all physicians in Arizona collected at the time of license renewal (n = 3312, or 17.9% of all practicing physicians). METHODS: Primary outcomes were physician-reported HIE use for patient care summaries and for laboratory results. Secondary outcomes were 5 common HIE barriers among non-HIE users. The primary predictor was physician practice model: accountable care organization (ACO), clinically integrated network (CIN), or integrated delivery network (IDN) vs traditional care delivery model. Covariates included physician specialty, age, gender, and county of practice. RESULTS: Compared with physicians in traditional care delivery models, physicians in ACOs, CINs, or IDNs had significantly higher odds of using HIE to share both patient care summaries (P < .01) and laboratory results (P < .05 for ACOs), although associations varied across provider and practice characteristics. ACO providers not using HIE were more likely to cite a lack of connectivity and lack of information as HIE barriers. CONCLUSIONS: Providers in an emerging practice model are more likely to use HIE than those in a traditional care delivery model. However, nuances in these associations suggest a persistence of previously identified HIE gaps, and the barriers cited provide guidance for increasing HIE use among different practice types.

Staffing Up and Sustaining the Public Health Workforce.

OBJECTIVES: Estimate the number of full-time equivalents (FTEs) needed to fully implement Foundational Public Health Services (FPHS) at the state and local levels in the United States. METHODS: Current and full implementation cost estimation data from 168 local health departments (LHDs), as well as data from the Association of State and Territorial Health Officials and the National Association of County and City Health Officials, were utilized to estimate current and "full implementation" staffing modes to estimate the workforce gap. RESULTS: The US state and local governmental public health workforce needs at least 80 000 additional FTEs to deliver core FPHS in a post-COVID-19 landscape. LHDs require approximately 54 000 more FTEs, and states health agency central offices require approximately 26 000 more. CONCLUSIONS: Governmental public health needs tens of thousands of more FTEs, on top of replacements for those leaving or retiring, to fully implement core FPHS. IMPLICATIONS FOR POLICY AND PRACTICE: Transitioning a COVID-related surge in staffing to a permanent workforce requires substantial and sustained investment from federal and state governments to deliver even the bare minimum of public health services.

The Opportunity Cost of COVID for Public Health Practice: COVID-19 Pandemic Response Work and Lost Foundational Areas of Public Health Work.

This article has been temporarily removed by the publisher, Wolters Kluwer, due to a data quality issue. We regret any confusion this may have caused. This article will be published once production is complete on the Public Health Workforce Interest and Needs Survey supplemental issue. CONTEXT: There is little empirical evidence regarding the magnitude of the COVID-19 response across the public health workforce and the extent to which other public health programs were called upon to contribute to the response, potentially leading to less work being done in other public health programs during the COVID-19 pandemic. OBJECTIVES: To assess the composition of the workforce that contributed to the COVID-19 pandemic response during 2020-2022. DESIGN: A large, cross-sectional, nationally representative survey of the state and local public health agency workforce through the Public Health Workforce Interest and Needs Survey (PH WINS). SETTING: Nearly all state health agency-central offices (SHA-COs) and Big City Health Coalition (BCHC) member public health departments as well as a nationally representative sample of other local health departments (LHDs) with more than 25 staff members and serving more than 25 000 people participated in fall 2021. PARTICIPANTS: A sample of all individuals working at each SHA-CO or LHD as part-time or full-time employees, contractors, or other employee types was used. A total of 44 732 responses (35% of eligible respondents) were received. MAIN OUTCOME MEASURE: Main outcomes included the proportion of full-time equivalent (FTE) effort devoted to COVID-19 response work by quarter (Q) from Q1 2020 through Q1 2022. Predictors of interest included individual- and agency-level demographics, most notably an individual's self-reported public health program area. RESULTS: Staffing and hiring for the COVID-19 pandemic response was an ongoing effort that began in 2020 and lasted through 2022. During the pandemic, all public health program areas contributed at least 20% of their workforce time to COVID-19 response, peaking at 47-83% of the staff time, depending on the program area. CONCLUSIONS: There was a considerable public health opportunity cost to the public health systems' large and prolonged COVID-19 response. Persistent understaffing in the public health system remains an important issue.

Exploring the Relationship Between Local Governmental Spending on the Social Determinants of Health and Health Care Costs of Privately Insured Adults.

Greater investment in the social determinants of health (SDOH) is positively associated with improved health outcomes of both individuals and their communities, which in turn may help to bend the health care cost curve and reduce health care spending. The purpose of this study was to examine the relationship between local governments' spending on the SDOH and the health care costs of privately insured nonelderly adults. Annual spending by local governments on the SDOH for the years 2007-2017 was obtained from the Census of Governments. Annual health care costs for privately insured nonelderly adults for the years 2013-2017 was obtained from the Health Care Cost Institute. Bivariate and multivariate regression analyses were performed to examine the association between county-level local governments' per capita spending on the SDOH and the per member health care costs of privately insured adults living in these counties controlling for community characteristics. All analyses were conducted in 2021. For near-elderly adults ages 55-64, health care costs were significantly higher in counties with the lowest levels of local governmental spending on the SDOH. For adults ages 18-54, in contrast, health care costs were unrelated to local governmental spending. Investments of local governments in the SDOH may have rather limited potential to yield meaningful savings in health care costs for privately insured nonelderly adults at the population level, especially once such investments exceed a minimum threshold.

Past local government health spending was not correlated with COVID-19 control in US counties.

CONTEXT: Wide variation in state and county health spending prior to 2020 enables tests of whether historically better state and locally funded counties achieved faster control over COVID-19 in the first 6 months of the pandemic in the Unites States prior to federal supplemental funding. OBJECTIVE: We used time-to-event and generalized linear models to examine the association between pre-pandemic state-level public health spending, county-level non-hospital health spending, and effective COVID-19 control at the county level. We include 2,775 counties that reported 10 or more COVID-19 cases between January 22, 2020, and July 19, 2020, in the analysis. MAIN OUTCOME MEASURE: Control of COVID-19 was defined by: (i) elapsed time in days between the 10th case and the day of peak incidence of a county's local epidemic, among counties that bent their case curves, and (ii) doubling time of case counts within the first 30 days of a county's local epidemic for all counties that reported 10 or more cases. RESULTS: Only 26% of eligible counties had bent their case curve in the first 6 months of the pandemic. Government health spending at the county level was not associated with better COVID-19 control in terms of either a shorter time to peak in survival analyses, or doubling time in generalized linear models. State-level public spending on hazard preparation and response was associated with a shorter time to peak among counties that were able to bend their case incidence curves. CONCLUSIONS: Increasing resource availability for public health in local jurisdictions without thoughtful attention to bolstering the foundational capabilities inside health departments is unlikely to be sufficient to prepare the country for future outbreaks or other public health emergencies.

Regarding Investment in a Healthier Future: Impact of the 2012 Institute of Medicine Finance Report.

CONTEXT: Governments at all levels work to ensure a healthy public, yet financing, organization, and delivery of public health services differ across the United States. A 2012 Institute of Medicine Finance report provided a series of recommendations to ensure a high-performing and adequately funded public health infrastructure. OBJECTIVES: This review examines the influence of the Finance report's 10 recommendations on public health policy and practice. DESIGN: This review utilized peer-reviewed and gray literature published since 2012. ELIGIBILITY CRITERIA: Documents that address at least one of the Finance report's 10 recommendations and contain information on either official actions taken in response to the Finance report or evidence of the report's influence on the practice community. RESULTS: Of 2394 unique documents found, a total of 56 documents met the eligibility criteria. Review of these 56 documents indicated that the most substantial activity related to the recommendations was focused on the "minimum package of public health services" concept and establishment of a uniform chart of accounts. DISCUSSION: Progress has been mixed on the Finance report recommendations. Improved tracking and auditing of public health activity appears to be advancing, yet financial benchmarks remain unmet. Challenges remain in determining actual investment in public health and equitable resource allocation approaches. State and local health department use of cost estimation methodology and a uniform chart of accounts tool has contributed to an increase in understanding and improvement in public health spending. CONCLUSIONS: The Finance report has served as a strong impetus for advocating for an increased investment in governmental public health. Efforts are bolstered by informed public health practitioners and stakeholders but often stymied by policy makers who must balance complex competing issues and priorities. Although many successes have occurred, further work is needed toward improving investment in the nation's public health.

Funding Public Health: Achievements and Challenges in Public Health Financing Since the Institute of Medicine's 2012 Report.

OBJECTIVE: The purpose of this study was to review changes in public health finance since the 2012 Institute of Medicine (IOM) report "For the Public's Health: Investing in a Healthier Future." DESIGN: Qualitative study involving key informant interviews. SETTING AND PARTICIPANTS: Purposive sample of US public health practitioners, leaders, and academics expected to be knowledgeable about the report recommendations, public health practice, and changes in public health finance since the report. MAIN OUTCOME MEASURES: Qualitative feedback about changes to public health finance since the report. RESULTS: Thirty-two interviews were conducted between April and May 2019. The greatest momentum toward the report recommendations has occurred predominantly at the state and local levels, with recommendations requiring federal action making less progress. In addition, much of the progress identified is consensus building and preparation for change rather than clear changes. Overall, progress toward the recommendations has been slow. CONCLUSIONS: Many of the achievements reported by respondents were characterized as increased dialogue and individual state or local progress rather than widespread, identifiable policy or practice changes. Participants suggested that public health as a field needs to achieve further consensus and a uniform voice in order to advocate for changes at a federal level. IMPLICATIONS FOR POLICY AND PRACTICE: Slow progress in achieving 2012 IOM Finance Report recommendations and lack of a cohesive voice pose threats to the public's health, as can be seen in the context of COVID-19 emergency response activities. The pandemic and the nation's inadequate response have highlighted deficiencies in our current system and emphasize the need for coordinated and sustained core public health infrastructure funding at the federal level.

County health outcomes linkage to county spending on social services, building infrastructure, and law and order.

Will counties that reallocate money from law enforcement to social services improve subsequent markers of population wellbeing? In this study, we measure the association between county government spending across multiple sectors and Life Expectancy at Birth (LEB) in the U.S. using data from the U.S. Census Bureau. We constructed a Structural Equation Model to determine whether social expenditure, building infrastructure, and spending on law and order were positively or negatively associated with LEB three-years after initial spending. The analysis compared data between 2002-05 and 2007-10 and was stratified for urban and rural counties. In rural counties, a one-standard-deviation increase in social spending increased subsequent LEB by 0.58 (SE 0.16) and 0.36 (SE 0.16) years in 2005 and 2010, respectively. In urban counties, a one-standard-deviation increase in building infrastructure spending increased subsequent LEB by 1.14 (SE 0.51) and 1.05 (SE 0.49) years in 2005 and 2010, respectively. In 2002, a one-standard-deviation increase in law and order spending significantly decreased subsequent life expectancy, 2.2 (SE 1.27) and 0.46 (SE 0.13) years in urban and rural counties, respectively. Similarly, investments in building infrastructure for urban counties and social services for rural counties were associated with subsequently higher life expectancy three years later after initial investments.

Association Between K-12 School Mask Policies and School-Associated COVID-19 Outbreaks - Maricopa and Pima Counties, Arizona, July-August 2021.

CDC recommends universal indoor masking by students, staff members, faculty, and visitors in kindergarten through grade 12 (K-12) schools, regardless of vaccination status, to reduce transmission of SARS-CoV-2, the virus that causes COVID-19 (1). Schools in Maricopa and Pima Counties, which account for >75% of Arizona's population (2), resumed in-person learning for the 2021-22 academic year during late July through early August 2021. In mid-July, county-wide 7-day case rates were 161 and 105 per 100,000 persons in Maricopa and Pima Counties, respectively, and 47.6% of Maricopa County residents and 59.2% of Pima County residents had received at least 1 dose of a COVID-19 vaccine. School districts in both counties implemented variable mask policies at the start of the 2021-22 academic year (Table). The association between school mask policies and school-associated COVID-19 outbreaks in K-12 public noncharter schools open for in-person learning in Maricopa and Pima Counties during July 15-August 31, 2021, was evaluated.

US Public Health Neglected: Flat Or Declining Spending Left States Ill Equipped To Respond To COVID-19.

The COVID-19 pandemic has prompted concern about the integrity of the US public health infrastructure. Federal, state, and local governments spend $93 billion annually on public health in the US, but most of this spending is at the state level. Thus, shoring up gaps in public health preparedness and response requires an understanding of state spending. We present state spending trends in eight categories of public health activity from 2008 through 2018. We obtained data from the Census Bureau for all states except California and coded the data by public health category. Although overall national health expenditures grew by 4.3 percent in this period, state governmental public health spending saw no statistically significant growth between 2008 and 2018 except in injury prevention. Moreover, state spending levels on public health were not restored after cuts experienced during the Great Recession, leaving states ill equipped to respond to COVID-19 and other emerging health needs.

Excess Medical Care Spending: The Categories, Magnitude, and Opportunity Costs of Wasteful Spending in the United States.

Landmark reports from reputable sources have concluded that the United States wastes hundreds of billions of dollars every year on medical care that does not improve health outcomes. While there is widespread agreement over how wasteful medical care spending is defined, there is no consensus on its magnitude or categories. A shared understanding of the magnitude and components of the issue may aid in systematically reducing wasteful spending and creating opportunities for these funds to improve public health.To this end, we performed a review and crosswalk analysis of the literature to retrieve comprehensive estimates of wasteful medical care spending. We abstracted each source's definitions, categories of waste, and associated dollar amounts. We synthesized and reclassified waste into 6 categories: clinical inefficiencies, missed prevention opportunities, overuse, administrative waste, excessive prices, and fraud and abuse.Aggregate estimates of waste varied from $600 billion to more than $1.9 trillion per year, or roughly $1800 to $5700 per person per year. Wider recognition by public health stakeholders of the human and economic costs of medical waste has the potential to catalyze health system transformation.

Reduction in US Health Care Spending Required to Meet the Institute of Medicine's 2030 Target.

Objectives. To quantify changes in US health care spending required to reach parity with high-resource nations by 2030 or 2040 and identify historical precedents for these changes.Methods. We analyzed multiple sources of historical and projected spending from 1970 through 2040. Parity was defined as the Organisation for Economic Co-operation and Development (OECD) median or 90th percentile for per capita health care spending.Results. Sustained annual declines of 7.0% and 3.3% would be required to reach the median of other high-resource nations by 2030 and 2040, respectively (3.2% and 1.3% to reach the 90th percentile). Such declines do not have historical precedent among US states or OECD nations.Conclusions. Traditional approaches to reducing health care spending will not enable the United States to achieve parity with high-resource nations; strategies to eliminate waste and reduce the demand for health care are essential.Public Health Implications. Excess spending reduces the ability of the United States to meet critical public health needs and affects the country's economic competitiveness. Rising health care spending has been identified as a threat to the nation's health. Public health can add voices, leadership, and expertise for reversing this course.

Aligning US Spending Priorities Using the Health Impact Pyramid Lens.

Thomas Frieden's "health impact pyramid" presents a hierarchy in which the wide base of the pyramid of socioeconomic factors at a population level has more impact on the health of the public than do individually focused interventions at the pyramid's top.From this pyramid perspective, the US spending priorities are misaligned, as expenses targeted at public health and socioeconomic factors are far outstripped by spending on individual health care services at the top of the pyramid. The nation's ongoing debate on health care reform continues to focus on access to individual health care services, despite evidence demonstrating the health impacts of population-level efforts at the base of the pyramid and the synergistic health impacts of health and social service collaboration.We examine the need for improved systems alignment through the lens of the health impact pyramid. We catalog the types of misalignments and their social, political, and systems genesis. We identify promising opportunities to realign US health spending toward the socioeconomic factor base of the health impact pyramid and emphasize the need to integrate and align public health, social services, and medical care in the United States.

Integration of Health and Social Services at the Systems Level: A Framework for Addressing Funding and Jurisdictional Silos.

Objectives. To examine spending and resource allocation decision-making to address health and social service integration challenges within and between governments.Methods. We performed a mixed methods case study to examine the integration of health and social services in a large US metropolitan area, including a city and a county government. Analyses incorporated annual budget data from the city and the county from 2009 to 2018 and semistructured interviews with 41 key leaders, including directors, deputies, or finance officers from all health care-, health-, or social service-oriented city and county agencies; lead budget and finance managers; and city and county executive offices.Results. Participants viewed public health and social services as qualitatively important, although together these constituted only $157 or $1250 total per capita spending in 2018, and per capita public health spending has declined since 2009. Funding streams can be siloed and budget approaches can facilitate or impede service integration.Conclusions. Health and social services should be integrated through greater attention to the budgetary, jurisdictional, and programmatic realities of health and social service agencies and to the budget models used for driving the systems-level pursuit of population health.

Inaccuracy of Official Estimates of Public Health Spending in the United States, 2000-2018.

Objectives. To examine the accuracy of official estimates of governmental health spending in the United States.Methods. We coded approximately 2.7 million administrative spending records from 2000 to 2018 for public health activities according to a standardized Uniform Chart of Accounts produced by the Public Health Activities and Services Tracking project. The official US Public Health Activity estimate was recalculated using updated estimates from the data coding.Results. Although official estimates place governmental public health spending at more than $93 billion (2.5% of total spending on health), detailed examination of spending records from state governments shows that official estimates include substantial spending on individual health care services (e.g., behavioral health) and that actual spending on population-level public health activities is more likely between $35 billion and $64 billion (approximately 1.5% of total health spending).Conclusions. Clarity in understanding of public health spending is critical for characterizing its value proposition. Official estimates are likely tens of billions of dollars greater than actual spending.Public Health Implications. Precise and clear spending estimates are material for policymakers to accurately understand the effect of their resource allocation decisions.

The State of Rural Public Health: Enduring Needs in a New Decade.

Public health in the rural United States is a complex and underfunded enterprise. While urban-rural disparities have been a focus for researchers and policymakers alike for decades, inequalities continue to grow. Life expectancy at birth is now 1 to 2 years greater between wealthier urban and rural counties, and is as much as 5 years, on average, between wealthy and poor counties.This article explores the growth in these disparities over the past 40 years, with roots in structural, economic, and social spending differentials that have emerged or persisted over the same time period. Importantly, a focus on place-based disparities recognizes that the rural United States is not a monolith, with important geographic and cultural differences present regionally. We also focus on the challenges the rural governmental public health enterprise faces, the so-called "double disparity" of worse health outcomes and behaviors alongside modest investment in health departments compared with their nonrural peers.Finally, we offer 5 population-based "prescriptions" for supporting rural public health in the United States. These relate to greater investment and supporting rural advocacy to better address the needs of the rural United States in this new decade.