Financing for a public health activity
Answer these discussion questions
1/What are potential sources of financing for a public health activity included in your topic area?
2/Provide an argument to support making an investment to support your topic using an ROI (return on investment) or to argue for a funding increase.
3/Make a recommendation for sources of funding for a public health activity in your chosen topic.
use these two link and other sources in the file to support your answer, do not forget to cite and add the bibliography.
https://asunow.asu.edu/20180727-solutions-asu-analysis-public-health-spending
https://www.tfah.org/assets/files/TFAH-2018-InvestInAmericaRpt-FINAL.pdf
By Glen P. Mays and Sharla A. Smith
Evidence Links Increases In Public
Health Spending To Declines In
Preventable Deaths
ABSTRACT Public health encompasses a broad array of programs designed
to prevent the occurrence of disease and injury within communities. But
policy makers have little evidence to draw on when determining the value
of investments in these program activities, which currently account for
less than 5 percent of US health spending. We examine whether changes
in spending by local public health agencies over a thirteen-year period
contributed to changes in rates of community mortality from preventable
causes of death, including infant mortality and deaths due to
cardiovascular disease, diabetes, and cancer. We found that mortality
rates fell between 1.1 percent and 6.9 percent for each 10 percent increase
in local public health spending. These results suggest that increased
public health investments can produce measurable improvements in
health, especially in low-resource communities. However, more money by
itself is unlikely to generate significant and sustainable health gains;
improvements in public health practices are needed as well.
D espite devoting far more resourc- es to health than any other coun- try in the world, the United States continues to lag behind many other industrialized nations in
health outcomes, including morbidity and mortality.1 Although there are many factors that contribute to this gap between resources and outcomes, one possible contributor is the relatively
limited investment in public health activities
that are designed to promote health and prevent
disease and disability.2–5 These activities include
efforts to monitor community health status; investigate and control disease outbreaks; educate
the public about health risks and prevention
strategies; enforce public health laws and regulations such as those concerning tobacco use;
and inspect and ensure the safety and quality
of water, food, air, and other resources necessary
for health.6
Although national data on public health
spending are scarce and imperfect, estimates
consistently indicate that less than 5 percent
of national health spending is devoted to public
health activities.7–9 In fact, the United States
spends more on administrative overhead for
medical care and health insurance than it does
on public health activities.10
The resources invested in public health strategies within the United States vary widely across
states and communities, yet the effects of this
variation on population health remain poorly
understood. Consequently, public health officials and policy makers face considerable uncertainty regarding the appropriate levels and targets of investing in public health activities.
The Affordable Care Act of 2010 authorized the
largest expansion in federal public health spending in decades—a projected $15 billion in new
spending over ten years—with the goals of improving population health, reducing health disparities, and helping to “bend the cost curve” by
moderating growth in medical care spending.
However, uncertainties regarding the expected
doi: 10.1377/hlthaff.2011.0196
HEALTH AFFAIRS 30,
NO. 8 (2011): 1585–1593
©2011 Project HOPE—
The People-to-People Health
Foundation, Inc.
Glen P. Mays (gpmays@
uams.edu) is a professor in
and the chairman of the
Department of Health Policy
and Management at the Fay
W. Boozman College of Public
Health, University of Arkansas
for Medical Sciences, in Little
Rock.
Sharla A. Smith is a research
associate in the Department
of Health Policy and
Management, University of
Arkansas for Medical
Sciences.
August 2011 30:8 Health Affairs 1585
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Meanwhile, a persistent economic downturn
has precipitated large cuts in state and local
government support for public health activities,
which has raised concerns about future adverse
consequences for population health.
To shed light on these uncertainties, this study
uses measures of public health spending from
local public health agencies over a thirteen-year
period to estimate the effects of this spending on
preventable mortality rates.
Background
Public health activities in the United States are
supported through a patchwork of funding
sources and financing arrangements that vary
widely across states and communities and that
are relatively unstable over time.13,14 These arrangements result in large geographic differences in spending for public health activities, even
among communities with relatively similar population characteristics and health needs.15
At the state level, per capita public health
spending varied by a factor of more than thirty
in 2010, ranging from a low of less than $4 in
Nevada to a high of more than $171 in Hawaii.9
Local variation in public health spending was
even larger, ranging from less than $1 per capita
to more than $200 per capita in 2008; among
local public health agencies the median spent
was about $36 per person.16 Many communities
depend heavily on local tax bases to support
public health programs, making it difficult for
economically disadvantaged communities to
support a comprehensive array of activities.17
Because only 16 percent of funding for public
health activities is derived from the federal
government,7 federal spending is insufficient
to equalize large differences in funding—from
taxes—of public health programs across localities.18
The amount of resources expended on public
health activities in a given community is determined through a complex interaction of economic conditions and fiscal capacities, community health needs, policy priorities, and delivery
system characteristics.15 Community-level variation in public health spending may result from
differences in the mix of activities produced; differences in the volume, intensity, and quality of
activities produced; and differences in the production and delivery costs incurred.
Higher levels of spending may contribute to
improved population health if resources are allocated to activities that are effective in reducing
health risks, and if these activities are targeted
successfully to population groups at risk. However, communities may vary considerably in how
effectively and efficiently resources are used to
address community health needs, thereby weakening the effect of spending on population
health. Research has documented such disconnects between spending and outcomes in local
medical care delivery.19
On balance, there is very little empirical evidence about the extent to which differences in
public health spending levels contribute to differences in population health.20 Several crossnational studies have found weak and conflicting
associations between spending and health outcomes at a national level.21–23 In the United
States, severaltime-series studies have examined
associations between spending levels and health
outcomes for specific types of programs such as
those targeting HIV prevention, sexually transmitted disease prevention, and tobacco control,
finding that disease incidence and/or harmful
behaviors declined as expected in response to
funding increases.24–28
However, very little attention has been paid to
the value of investments in the public health
system as a whole, leading to persistent questions about whether the nation’s current spending levels are worth the opportunity costs. Better
evidence about the consequences of these spending patterns is likely to help policy makers at all
levels of government make informed decisions
about how to allocate scarce health resources.
To this end, we assembled a unique longitudinal database that included local government
public health spending, population characteristics, and community mortality rates, in order to
estimate how changes in public health spending
influence population health.We used the considerable natural variation in public health spending levels across communities, and the considerable change in these levels over time, to
estimate health effects.
This study focuses on spending and health at
the local level because local public health agencies—rather than their state and federal counterparts—assume primary responsibility for directly implementing public health activities in
most communities.29 Most federal and state
funding—and large amounts of private philanthropic funding—for public health activities is
channeled through local public health agencies.
The local agencies also mobilize and coordinate
the public health activities of hospitals, health
plans, and community-based organizations.30
Thus, these agencies provide valuable settings
in which to study the health consequences of
public health spending in the United States.
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For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.Study Data And Methods
We analyzed changes in spending patterns and
mortality rates within the service areas of the
nation’s nearly three thousand local public
health agencies over a thirteen-year period.
The study population included all organizations
that met the National Association of County and
City Health Officials’ definition of a local health
department: a unit of a local or state government
that has responsibility for performing public
health functions for a geopolitical jurisdiction
smaller than a state.16 In 2005 approximately
73 percent of these agencies served county jurisdictions or combined city and county jurisdictions, and the remaining agencies served city
or township jurisdictions (16 percent), or multicounty or regional jurisdictions (11 percent).
Data Sources And Measures The National
Association of County and City Health Officials
collected spending data along with organizational and operational characteristics of local
public health agencies through census surveys
conducted in 1993, 1997, and 2005. Key variables
reflecting annual agency spending, service offerings, and staffing levels were collected in each
year of the survey.We linked the survey data with
contemporaneous county-level data on population characteristics and health resources from
the Health Resources and Services Administration’s Area Resource File (a national county-level
health resource information database), federal
and state spending estimates from the Census
Bureau’s Consolidated Federal Funds Report and
Census of Governments, and cause-specific mortality rates from the Centers for Disease Control
and Prevention’s Compressed Mortality File.
As outcome measures, we used mortality rates
that were expected to be sensitive to public
health interventions over the thirteen-year
period of study,31,32 including the age-adjusted
all-cause mortality rate, the infant mortality rate,
and the age-adjusted mortality rates for heart
disease, cancer, diabetes, and influenza. Two
additional mortality measures were selected as
control conditions based on the expectation that
they would not be influenced by public health
resources and interventions during the study
period. These measures included mortality from
Alzheimer’s disease and a measure of residual
mortality indicating deaths not attributable to
heart disease, cancer, diabetes, chronic obstructive pulmonary disease, influenza, cerebrovascular diseases, or unintentional injuries.
The primary independent variable of interest
in this analysis is the measure of per capita local
public health spending, defined as the total annual spending of the local public health agency,
divided by the total population residing within
the jurisdiction of the agency. We also constructed measures of direct state and federal public health spending that were not passed through
to local public health agencies. Other measures
reflecting community demographic and socioeconomic characteristics and area health resources are used as control variables in the analysis (Exhibit 1).
Analytic Methods Multivariate regression
models for panel data were used to estimate
the effect of local public health spending on each
mortality measure while controlling for the effects of other community characteristics that influence population health. Time-trend variables
were used in the models to account for general
downward trends in mortality that occurred
independently of spending.
An important methodological complication
arises in this analysis because local public health
spending levels may be influenced by unobserved community characteristics that simultaneously influence mortality. For example,
deteriorating local economic conditions may
cause public health spending to decline and mortality risks to rise, resulting in incorrect inferences about how spending influences mortality.
To addressthis possible source of bias, we used
instrumental variables methods to distinguish
the effects of spending on mortality from the
effects of unmeasured characteristics that simultaneously influence spending and mortality.33,34
This methodology requires the identification of
variables that influence local public health
spending but have no direct effects on community mortality rates. We used measures of local
public health decision-making structures for this
purpose, including whether the agency is governed by a local board of health with policy making authority, and whether the agency operates
under the centralized administrative control of
state government. Theory and previous studies
indicate that these characteristics influence the
ability and inclination of local public health
agencies to secure external funding sources for
their work.15,35–37
Specification tests38 confirm that the structural characteristics meet the requirements for
instrumental variables (see the Appendix).39 Using a two-step process, we first estimated the
effect of the instrumental variables on spending
levels, and then used the natural variation in
spending produced by these variables to estimate how spending affects mortality.
Limitations Several limitations of this analysis are worthy of emphasis. Although we used
strong statistical controls to address possible
sources of bias,34,35 it remains possible that factors distinct from, but closely correlated with,
public health spending may explain some of
the observed associations between spending
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on selected mortality rates as measures of population health, not on other indicators of disease
burden or quality of life.
Local public health activities may have important and perhaps more immediate effects on
these other indicators of health. Moreover, the
thirteen-year time period used in this study is
insufficient for observing the complete, longterm effects of public health interventions on
chronic disease mortality rates. Consequently,
this analysis may underestimate the health consequences of changes in local public health
spending.
Study Results
Variation In Spending And Mortality A general secular trend of growth in public health
spending and reductions in selected mortality
rates during the 1993–2005 period masked significant community-level differences. Local public health spending in the average community
reached $40.84 per capita in 2005, up from
$34.68 per capita in 1993 (Exhibit 1). However,
only 65 percent of agencies experienced positive
growth in per capita public health spending during the 1993–2005 period, while 35 percent of
agencies experienced spending reductions.
The degree of change in per capita spending
varied widely across communities. The top
20 percent of agencies experienced growth of
nearly 150 percent, while the bottom 20 percent
of agencies experienced reductions of nearly
45 percent during the study period. Meanwhile,
infant mortality and heart disease mortality rates
declined moderately during the same period,
continuing a longer-term secular trend downward, while cancer and diabetes mortality rose
slightly (Exhibit 1).
The rates of change in these outcomes varied
widely among communities. For example, the
top 20 percent of communities experienced a
reduction in age-adjusted heart disease mortality
Exhibit 1
Characteristics Of The Study Communities, 1993 And 2005
Variable 1993 mean 1993 SD 2005 mean 2005 SD
Public health agency characteristics
Per capita public health spending $34.68 $33.08 $40.84 $42.52
Agency governed by local board of health 64.41% 57.42%
Agency operates as centralized unit of state agency 10.27% 7.83%
Community characteristics
Population size (1,000s) 108.63 340.60 131.44 426.42
Population per square mile (1,000s) 475.08 1,841.46 484.04 1,842.57
Community located within a metropolitan area 51.05% 50.48%
Percent of:
Population nonwhite 14.33 17.93 19.27 17.36
Population 65 or older 14.39 3.91 14.07 4.00
Population with college degree 15.85 8.25 19.59 9.53
Population unemployed 6.21 2.42 5.64 2.26
Population below federal poverty level 15.65 7.04 11.92 4.79
Population non–English speaking 1.07 1.77 1.73 2.32
Population uninsured 13.66 4.65 13.52 4.50
Medical care resources
Active physicians per 100,000 population 138.04 133.83 169.24 159.23
Hospital beds per 100,000 population 384.16 320.51 320.60 372.81
Federally qualified health center serves community 48.33% 46.57%
Health outcomes
Infant deaths per 1,000 live births 8.76 3.50 7.03 3.22
Deaths per 100,000 population from:
Influenza 36.11 17.66 27.28 15.52
Cancer 215.46 56.16 219.49 57.99
Heart disease 225.02 78.87 194.09 76.95
Diabetes 23.47 10.58 28.67 14.41
Total deaths per 100,000 population 1,020.97 256.59 980.62 270.68
Number of observations 2,026 2,300
SOURCE Authors’ analysis of linked data from the National Association of County and City Health Officials’ National Profile of Local Health Departments, the Census
Bureau’s Census of Governments and Consolidated Federal Funds Report, the Health Resources and Services Administration’s Area Resource File, and the Centers for
Disease Control and Prevention’s Compressed Mortality File. NOTE SD is standard deviation.
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increase by forty-three deaths per 100,000 people. Overall, population size, educational attainment, physician availability, and number of people above the federal poverty level increased in
the average community during this period.
Determinants Of Public Health Spending
Local decision-making structures influenced
public health spending levels considerably. Per
capita spending was more than 17 percent higher
in communities governed by a local board of
health, compared to communities without such
boards (p < 0:001) (Exhibit 2). Moreover,
spending was 24 percent lower among agencies
that operated under the centralized administrative control of state agencies, as compared to
independent local agencies.
Public health spending increased with social
indicators of community health need, including
the unemployment rate, the uninsured rate, and
the nonwhite racial composition of the community, whereas spending decreased with the availability of selected medical resources in the community (Exhibit 2).
Effects Of Spending On Mortality Increases in public health spending were associated with statistically significant reductions in
mortality for four of the six mortality rates we
examined (Exhibit 3). The strongest effects were
found for infant mortality and cardiovascular
disease mortality, indicating that mortality rates
fell by 6.9 percent and 3.2 percentfor each 10 percent increase in spending (p < 0:05). Diabetes
mortality fell by 1.4 percent and cancer mortality
fell by 1.1 percent for each 10 percent increase in
spending (p < 0:05).
Influenza mortality and total mortality
changed in the expected direction, but did not
reach statistical significance. Public health
spending showed no association with the two
control conditions, Alzheimer’s mortality and
residual mortality, helping us to rule out the
possibility of spurious associations between
spending and mortality.
Overall, public health spending emerged as
one of the most consistent determinants of community-level preventable mortality. Most of the
other variables that were consistently associated
with reductions in mortality reflected social determinants of health, including educational attainment, percentage of the population above
the federal poverty level, and percentage of the
population that was white (see the Appendix).39
Medical resource variables were not consistently
associated with mortality after controlling for
the effects of other variables in the analysis.
Discussion
Communities with larger increases in public
health spending experienced larger reductions
Exhibit 2
Influence Of Selected Characteristics On Local Public Health Spending
Characteristic Percent change in spending
Public health agency characteristics
Agency governed by local board of health 0.169***
Agency operates as centralized unit of state agency −0:240***
Community characteristics
Population per square mile (1,000s) 0.001
Community lies within a metropolitan area −0:388***
Percent of population nonwhite 0.008***
Percent of population 65 or older 0.010
Percent of population with college degree −0:011***
Unemployment rate 0.013**
Percent of population below federal poverty level 0.005
Percent of population non–English speaking −0:068***
Percent of population uninsured 0.037***
Medical care resources
Active physicians per 100,000 population 0.002
Hospital beds per 100,000 population −0:002***
Federally qualified health center serves community −0:174***
SOURCE Authors’ analysis of linked data from the National Association of County and City Health Officials’ National Profile of Local
Health Departments, the Census Bureau’s Census of Governments and Consolidated Federal Funds Report, the Health Resources and
Services Administration’s Area Resource File, and the Centers for Disease Control and Prevention’s Compressed Mortality File. NOTE
This table shows coefficient estimates from a semilogarithmic regression model that controls for demographic, socioeconomic, and
health resources characteristics and community-specific random effects. **p < 0:05 ***p < 0:01
August 2011 30 :8 Health Affairs 1589
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For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.in mortality from leading preventable causes of
death over a thirteen-year period. This relationship was consistent across several different
mortality measures, and it persisted after accounting for differences in demographic and
socioeconomic characteristics, medical resources, and unobserved community characteristics
that jointly influence spending and health. These
findings are consistent with recent time-series
studies estimating that, nationally, as much as
50 percent of the gains in life expectancy experienced in the United States since 1950 are attributable to public health attention to diet, tobacco
exposure, and other measures.40–44
Although our study does not establish a definitive causal link between spending and mortality
because of the observational research design we
used, it nevertheless provides compelling evidence that differences in public health investments may contribute to differences in community health outcomes. Consequently, efforts to
improve community health and reduce geographic disparities in mortality are likely to require attention not only to local medical resources and interventions, but also to the resources
invested in local public health activities.
The findings imply that the mortality reductions attributable to increases in public health
spending are sizable, and may exceed the reductions achievable through similar expansions in
local medical care resources. For example, our
estimates suggest that a 10 percent increase in
public health spending could achieve a 3.2 percent reduction in cardiovascular mortality. This
spending increase would require an additional
$312,274 in annual funding in the average metropolitan community included in our analysis.
Achieving this same mortality reduction by
increasing the number of primary care physicians would require an additional twenty-seven
physicians in the average metropolitan community, based on a recent analysis of physician supply.45 Increasing the physician supply by this
amount would probably require new spending
considerably in excess of the amount needed to
achieve the mortality reduction through public
health spending. The potential for substitution
and synergy between public health and medical
care resources is an important area for further study.
The strongest associations between spending
and mortality were observed for infant mortality,
cardiovascular disease, diabetes, and cancer—
four of the preventable health conditions most
commonly targeted by public health agencies. In
2005, 73 percent of the nation’s local health departments maintained screening and/or riskreduction programs for cardiovascular disease
or high blood pressure, 74 percent delivered maternal and infant health programs involving nutrition and/or prenatal care, and 69 percent
performed activities to reduce tobacco exposure—a risk factor for all four causes of death.16
Evidence-based public health interventions
areknownto address risk factorsforthese causes
of death.46–48 The observed associations between
spending and mortality are consistent with the
expectation that higher levels of spending allow
public health agencies to implement these types
of risk-reduction activities more effectively
within their communities.
Influenza mortality and total mortality did not
appear sensitive to public health spending in our
analysis. A combination of factors may explain
Exhibit 3
Effects Of Local Public Health Spending On Community Mortality Rates
Mortality rate
Percent change per
10% increase in spending
Infant deaths per 1,000 live births −6:85***
Heart disease deaths per 100,000 population −3:22**
Diabetes deaths per 100,000 population −1:44**
Cancer deaths per 100,000 population −1:13**
Influenza deaths per 100,000 population −0:25
All-cause deaths per 100,000 population −0:29
Alzheimer’s deaths per 100,000 population 0.25
Residual deaths per 100,000 population 0.18
SOURCE Authors’ analysis of linked data from the National Association of County and City. Health Officials’ National Profile of Local
Health Departments, the Census Bureau’s Census of Governments and Consolidated Federal Funds Report, the Health Resources and
Services Administration’s Area Resource File, and the Centers for Disease Control and Prevention’s Compressed Mortality File. NOTE
This table shows coefficient estimates obtained from instrumental variables estimation of semilogarithmic regression models for
panel data that control for demographic, socioeconomic, and health resources characteristics and community-specific random
effects. **p < 0:05 ***p < 0:01
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For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.the influenza result, including the dearth of
effective community-based interventions for
achieving high vaccination rates, random variation in influenza lethality, and inconsistencies in
how deaths are attributed to influenza.49 For total mortality, the lack of a significant spending
effect probably stems from the heterogeneous
disease processes reflected in this broad mortality measure and the many factors beyond public
health interventions that influence these
processes.
Our results suggest that additional spending,
such as the $15 billion in new federal funds authorized under the Affordable Care Act’s Prevention and Public Health Fund, would be expected
to generate substantial improvements in population health over time. At the same time, our
results suggest that the recent recession-driven
reductions in state and local support for public
health activities are likely to have adverse health
consequences over time unless they are offset
with new spending. Additional research is urgently needed to track the downstream effects
of these ongoing, unprecedented spending
shocks in public health. Our study provides a
foundation for these future investigations.
The mortality reductions attributable to public
health spending in this study represent average
effects across all US local public health agencies
and across all categories of local governmental
public health spending. Unfortunately, because
our analysis of spending was carried out at an
aggregate level, our results do not suggest how
future funding increases and reductions should
be allocated among the many programs and services maintained at the local level.
The aggregate nature of our analysis may also
explain the relatively modest mortality effects we
observed. By measuring spending levels in specific programmatic areas such as tobacco control, nutrition, and physical activity, it may be
possible to identify more precise relationships
between investments and health outcomes and
to examine the comparative effectiveness of each
type of spending. Such targeted studies will require much more detailed spending datathan are
currently available for local public health agencies nationwide, which calls attention to the
need for improved data systems to track public
health spending.
Our analysis supports the contention that
spending on local public health activities is a
wise health investment. Increasing such investments in communities with historically low levels of spending may provide an effective way of
reducing geographic disparities in population
health. However, more money by itself is
unlikely to generate significant and sustainable
health gains.
A growing body of evidence suggests that the
quality and efficiency of public health practice
within the United States have considerable room
for improvement, and progress in these areas
could greatly increase the value of additional
public health spending.35,50–54 Better systems
for tracking data on trends in public health
spending and the use of funds at local, state,
and national levels are needed to ensure that
resources are allocated wisely. Moreover, the resulting estimates of spending and their health
consequences must be accessibleto public health
officials, policy makers, and the public at large to
support informed decision making about societal investments in public health activities. ▪
August 2011 30 :8 Health Affairs 1591
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For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.This research was supported by the
Robert Wood Johnson Foundation’s
Changes in Health Care Financing and
Organization Program (Grant 56469) and
the Public Health Practice-Based
Research Networks Program (Grant
64676). Glen Mays also was supported
through a Clinical and Translational
Science Award from the National
Institutes of Health National Center for
Research Resources (Award
1UL1RR029884). Data for this study
were provided by the National
Association of County and City Health
Officials Profile of Local Health
Departments. The content is solely the
responsibility of the authors and does
not necessarily represent the official
views of the Robert Wood Johnson
Foundation, the National Institutes of
Health, or the National Association of
County and City Health Officials.
[Published online July 21, 2011.]
NOTES
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