What does it mean that the national Public Health Activity Estimate decreased 21% between 2020 and 2021? Something. Probably.

I get that people are here for end-of-the-year TV lists. What was the best thing in 2022? No idea, I’m only up on two of the shows in the Rotten Tomatoes top 25, though it’s not for lack of trying. For me, one of the promises of December each year is that we’ll be getting a sneak peek at the next iteration of the National Health Expenditure Accounts from the crew over at the CMS Office of the Actuary. This year’s article (currently, unfortunately, behind a subscription paywall), relays data from 2021 that finds growth in national health spending of about 3% from 2020, to $4.3 trillion overall. Reasonably, most of the focus of the article is how that is pretty slow growth and, as ever, how almost all of our spending is in personal health care and related areas.

To me, though, that’s not really the story I’m interested in. What jumps out, as with last year, is that our national Public Health Activity Estimate (the annual estimate of PH spending) is completely crazy. After more than doubling from 2019 to 2020 – going from $107 billion to $238 billion, it has now, apparently, declined to $188 billion in 2021.

Isn’t that something?

Figure 1: The Public Health Activity Estimate, 2015-2021

Source: CMS Office of the Actuary, Martin et al. Health Affairs, 2022. Note: Stacked boxes indicate share of revenue by source.

The real issue here is that we don’t actually know if these changes are real, or meaningful. Truth be told, a 21% decrease in public health spending in the middle of the pandemic should be shocking – headline news.  If real, one interpretation might reasonably be that without the full-scale mobilization of 2020 needed, some decreases are warranted. Conversely, I would make the argument that it actually takes quite a long time for appropriations to hit the books, so the fact that FY21 decreased is hugely problematic, and should be looked into.

That is, of course, if the numbers are real. As we’ve talked about before on this blog, it is desperately challenging to really know our national Public Health Activity Estimate. The literal, official dollar amount we spend on public health is neither precise nor accurate. There are a host of technical reasons for this, but it basically boils down to the fact that the data producer (the Census bureau) uses a slightly different definition of what constitutes public health than the creator of the Public Health Activity Estimate (CMS Office of the Actuary). I and others have complained about this a lot. It has meant that our national estimate is maybe a third higher to as much as 50% higher than reality. It has also meant their calculation of federal vs local/state revenue share is almost certainly mistaken, as illustrated in Figure 1 (federal has always likely been a much, much larger share than reflected in the estimates).

For CMS, this is honestly not such a big deal – the Public Health Activity Estimate is budget dust compared to the personal health care spending. But for us in public health? Whether we get three cents on the health dollar, or five cents, or two cents? You better believe that makes a difference if we’re going to Congress and arguing we need more money – if a Congressperson can reply and ask us 1) how much are we actually getting and 2) what are we doing with those dollars and we cannot answer … we are sunk.

This is a perennial problem in public health, one that crops up more than every December, but one I am often reminded of this time of year. For now, I’ll go back to being judged by my Spotify Wrapped list and considering watching a new, well-rated TV show before settling on an inevitable rewatch of Parks & Rec. Happy Holidays, all.


JP Leider, PhD, is the Director of the Center for Public Health Systems at the University of Minnesota School of Public Health, and a member of the JPHMP Editorial Board. He is available at leider (at) umn (dot) edu.