What’s the Deal with Public Health Funding?

by JP Leider, PhD


I woke up this morning and decided the question of public health funding deserved the Jerry Seinfeld treatment.

Like my colleagues who do disaster planning and are in public health more generally, I get many questions each day about COVID-19 and what the average citizen should do. Make no mistake, these questions are coming from a reasoned and reasonable place. As my governor said the other day, preparation is not panic. But I’ve had other interesting conversations, too, about our general underinvestment in public health. And we’re seeing these conversations also a bit more broadly in society. The speed and severity of COVID-19, while generically predicted as part of disaster planning for the past 20 years, is showing the cracks in the US public health system. Or, our system of systems. We have almost 3,000 state, local, territorial, and tribal health departments in this country. And they all look a little bit different from each other. But what is consistent, almost to a health department, is that they have been chronically underfunded.

Despite public health saving lives, and doing so in a cost effective manner, governmental public health spending accounts for somewhere between one and three cents on every health dollar we spend in the US. We don’t even report how much we spend on public health correctly. We have systematically overestimated public health spending for decades, which makes these issues worse and more complicated, if you ask me. When you don’t know how much you are spending, it’s somewhat challenging to know how much you need.

About eight years ago, leading minds in public health said that we needed to double the federal investment in public health. Unfortunately, that recommendation had zero interest in Congress at the time, even after Zika and Ebola. The Prevention Fund, established by the ACA (and decried as a slush fund and later raided by the previous administration), now constitutes a large source of federal funding for public health – but at less than one billion dollars a year, it is far smaller than originally intended.

Cuts to the Prevention Fund Since Creation

Notes: The original allocation (blue bars) were established by the Patient Protection and Affordable Care Act (PL 110-48), while cuts (red bars) were established by the Bipartisan Budget Act of 2018 (Pt. 115-123, Current Law).

Source: Trust For America’s Health analysis of congressional committee reports.

Instead of growing our baseline capacity, we tend to inject huge sums of money into the public health system when disaster strikes. How do you scale up, and spend those dollars effectively, if you’ve lost a quarter of your workforce? More recently, there have been calls for about $4.5 billion to support the basic infrastructure, or core capabilities, of public health. Emergency preparedness is one of those capabilities. Funds were cut in the last administration (until Zika/Ebola), and it’s been attempted in this one, as well. Trust for America’s Health has said, for years, that disasters would be much harder to respond to without enough baseline public health funding. Here we are.

One of the things I’ve so appreciated about recent news articles and opinion pieces on the shortcomings of public health spending is the recognition that an agency has to have a strong core to have surge capacity. Surge capacity here includes the ability to bring all hands on deck to respond to crises, and to sustain that over time. You have to have a wide bench and a deep one to do both. But we just don’t in public health, not anymore. Since the Great Recession, we’ve lost 50,000 jobs at state and local health departments. We have a generation that’s ready to retire – the Baby Boomers. And young people are more likely to say that they’re considering leaving their job in governmental public health (for reasons other than retirement) and looking for more lucrative jobs with a better career trajectory elsewhere.

Every crisis brings an opportunity. JPHMP has been talking about public health finance and funding since its inception. It has a whole collection on the topic. Now, the world is interested in this topic. I hope those on JPHMPDirect can continue to serve as subject matter experts and support public health practitioners at all levels during these challenging times. But we also have to track the money going out the door, know where it ends up and what it achieves, and make the argument that federal, state, and local governments need to consistently invest in public health. Not just when there’s an outbreak. Or a pandemic.

Read All Posts in this Series:

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Jonathon P. Leider, PhD

Jonathon P. (JP) Leider, PhD, is an independent consultant in the public health and health policy space, as well as a Senior Lecturer at the University of Minnesota and Associate Faculty at the Johns Hopkins Bloomberg School of Public Health. He has active projects and collaborations with foundations, national public health organizations, public health researchers and academics, and public health practitioners. His current projects focus on public health systems, the public health workforce, and public health finance. He holds a PhD in Health Policy and Management from the Johns Hopkins Bloomberg School of Public Health. [Full bio]

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