America’s Public Health System – Part 3
The Shameful Fiscal Neglect and Political Denial of Public Health
This is the third essay in Civic Way’s series on public health. In our
last essay
, we discussed the organizational weaknesses of the public health system. In this essay, we address other factors hastening the public health system’s decline. The author, Bob Melville, is the founder of Civic Way, a nonprofit dedicated to good government, and a management consultant with over 45 years of experience improving public agencies.
Highlights:
The recent attacks on America’s public health system will not only destabilize our ability to preserve public health but protect our citizens from the next pandemic
The political war on public health—on our own people—will ultimately prolong pandemics, jeopardize community health, strain hospitals and cost lives
The public health system is essentially funded by a top-down federal funding model with federal funds a vital, and increasingly dominant revenue source for states and localities
In the decade before the pandemic, state public health spending fell by over 20 percent and public health spending varied dramatically among states and localities
While fully funding our federal, state and local public health programs will require a bigger investment (up to $4.5 billion more per year), a new public health funding model is also needed
The loss of over 56,000 workers in the last decade has left our public health system reeling
Betraying our Public Health System
World history is replete with brutal accounts of wars and military assaults. Iraq. Afghanistan. Vietnam. Pearl Harbor. The Battle of France. The Sack of Rome. And our focus on such threats still drives us. The US spends billions every year defending its citizens against military attacks by foreign powers.
Why don’t we have the same vigilance regarding other threats?
Make no mistake. The US public health system, our essential line of defense against other existential threats—pandemics, bioterrorism and transmittable disease—is under attack. This time, however, our foe is not a foreign nation. The enemy is us.
Millions of politicians and citizens have mounted a vicious assault on America’s public health system. Their strategy, while inexplicable to those aware of the risks, is simple but cynical. To win the next election, they have decided to characterize public health measures and workers as enemies of personal freedom. Under the misconstrued rallying cry of “Don’t Tread on Me,” they demand the right to tread on others.
This attack is not new, it is just more extreme. We have been betraying our public health system for decades. Repeated funding cuts have seriously weakened our nation’s public health infrastructure. We now spend far less on public health than other industrialized countries.
Even before the pandemic, experts warned that the US lacked sufficient public health resources to protect its citizens. The war on public health will remove all doubt.
The Political War Against Public Health
Since 2020, when public health was turned into a partisan political issue, at least 30 states have enacted new laws (over 100 at last count) undermining public health officials and measures. These laws limit state and local health powers in ways that risk our future health, if not survival, e.g.:
Curb the authority of local health boards to enact public health regulations
Empower governors, legislatures and commissions to modify or reverse health orders
Restrict the ability of local officials to impose public health quarantines or mandates (e.g., masks, closures, capacity limits, contact tracing and vaccines)
Set arbitrary time limits on executive emergency declarations and orders
Prevent state and local officials from enforcing public health orders (e.g., impose fines)
Make it easier for citizens to sue public health agencies that impose orders
In GOP-controlled states like Arkansas, this legislative mania has flouted the concerns of GOP governors about the health risks of such bills. In politically divided states like Wisconsin, legislators have used the courts to halt gubernatorial public health measures (e.g., mask mandates).
The politicization of public health has spread to localities, too. Local politicians and citizens harassing public health workers. Angry protests. Slurs and threats, not just against public health workers but their families. Unvaccinated Covid-19 patients verbally abusing the very health workers trying to help them. In some localities, electing demagogues who blast Covid-19 vaccinations as “needle rape.”
The long-term costs of this political war—this callous attack against our own people—will be devastating. Resisting public health initiatives like flu vaccination campaigns or measles quarantines will endanger community health. Evading childhood immunizations will cost lives. Undercutting pandemic measures will prolong pandemics, increase hospitalizations and risk lives.
Our Addiction to Federal Funding
During the pandemic and under both administrations, the federal government has poured billions into public health to fight the virus. For 2021, federal grants to state and local public health agencies totaled over $57 billion. The pandemic stimulus package included about $160 billion for public health.
This infusion of federal pandemic aid to public health programs, while needed, sent two signals. First, it reinforced a key element of our top-down public health system funding model—the dominance of the federal government in funding public health programs. Second, it led many to believe that public health funding is adequate for meeting our public health needs. The first impression is correct, the second one is not.
During the 20th century, states and localities grew increasingly dependent on federal funding for their public health programs. While Reagan significantly cut federal spending and even eliminated some public health programs, federal funding remains a vital revenue source for states and localities. As state and local budgets have flattened in recent decades, state and local dependence on federal funding has increased.
Federal funding for public health is inadequate. According to the Association of State and Territorial Health Officials, federal public health funding has struggled to keep pace with inflation, let alone the nation’s aggregate public health needs.
The CDC is another case in point. When the pandemic arrived, the CDC’s budget was little more than its FY08 budget, adjusted for inflation. Over the past decade, the CDC’s pre-pandemic funding for public health emergency programs was cut by half. Long before the pandemic, during the period from 2005 to 2012, the CDC’s budget was cut from $7.3 billion to $6.1 billion.
Given its importance to the viability of state and local public health programs, the long-term stagnation of federal public health funding is troubling. And with most of the nation’s health funding committed to programs like Medicare and Medicaid, this trend will be hard to reverse. For example, only ten percent of DHHS’ FY22 budget is for discretionary programs like public health.
The Starvation of State and Local Public Health Budgets
Even as federal public health spending has flattened, state and local dependence on federal grants has grown. As recently as 2015, the average state public health budget comprised about 48 percent federal funds, 40 percent state funds and 12 percent other sources (e.g., fees and fines). By FY18, about 55 percent of the average state budget’s total revenues were from the federal government.
Despite the growing importance of federal funding (or perhaps because of it), state and local public health programs have been suffering funding cuts for many years, long before the pandemic hit. The Great Recession hammered state and local governments, but its impact on public health agencies was particularly severe and lasting. It took over a decade for most public health budgets to return to pre-recession levels.
According to the Association of State and Territorial Health Officials, state public health spending fell by over 20 percent from 2010 to 2018. State allocations of federal public health funds fell by 20 percent from 2016 to 2018. Median state per capita spending fell by nearly 20 percent from 2008 to 2012.
Public health spending also varies dramatically among the states. According to the Pew Charitable Trust, per capita state and local public health spending ranges from less than $5 to over $100, a 20-fold gap between the highest and lowest states. This gap is often exacerbated by massive per capita federal funding differences among states (the per capita federal dollars received by states can differ by as a much as a factor of four).
This chronic underfunding of state public health programs is not necessarily a partisan issue. Ohio, a GOP-led state, does spend less on public health than the US median for states. However, Washington, a Democrat-led state, spends only about ten percent of its estimated annual need. Worse, 20 years ago, Washington voters approved measures that reduced dedicated funding sources for public health.
Not surprisingly, especially given the top-down funding mechanisms that characterize our nation’s public health system, local public health budgets suffered along with state public health budgets. Since 2010, per capita spending on local public health has fallen by nearly 20 percent.
Like states, local public health agencies receive a growing share of their revenues from the federal government (states allocate up to two-thirds of their federal funds to local public health programs). Most local public health agencies are funded by several sources, including state funds (including federal funds), fees for services, local appropriations, grants and donations. There is little evidence of a burgeoning local commitment to public health.
Our Outmoded Public Health Funding Scheme
Many experts bemoan public health funding levels. The Public Health Leadership Forum, for instance, asserts that, if we were to fully fund our federal, state and local public health programs, it would cost us an additional $4.5 billion per year. This issue demands our attention.
However, the level of funding for public health is not our only challenge. The way we fund public health in this country is deeply flawed as well. A few examples:
Political influence – public sector budget decisions often reflect the pressures exerted by powerful groups with sufficient lobbying resources to promote their interests, resources that public health agencies lack
Budget myopia – most public health programs require a long-term funding commitment to ensure their success, but the short-term government funding model forces public health officials to shift their attention from long-term goals like prevention and innovation to urgent issues like virus testing and disaster relief
Budget silos – yoking federal funds to overly specific program requirements can limit the flexibility of state and local officials to meet community health needs and build community partnerships
Funding criteria – federal funds are not consistently distributed to states and localities based on objective, need-based criteria, resulting in inexplicable discrepancies across states and even within the same state
Distribution delays – the flow of funds from federal agencies like the CDC to states and localities creates several points at which public health funds can be delayed, thereby hindering the ability of front-line public health agencies to meet community needs
Until we revamp the way we fund public health, merely increasing public health appropriations will likely disappoint. Huge political and profit incentives stand in the way. No matter how much we spend, we will be inclined to sacrifice long-term prevention and preparedness for short-term treatment and mitigation.
The Alarming Loss of Public Health Workers
Public health programs cannot succeed, chronic diseases cannot be prevented and pandemics cannot be vanquished without dedicated staff. And, regardless of how much money is needed to meet the nation’s public health needs, one fact cannot be disputed. Public health workers are leaving their profession at alarming rates.
The National Association of County and City Health Officials has reported that, in the past decade, public health agencies lost over 56,000 positions (about 25 percent of the total workforce). Since the Great Recession, it is estimated that rural health offices have lost about half of their full-time staff.
There are several contributing factors. Compensation is not competitive, especially given the profession’s high educational requirements. A large portion of the public health workforce, with over two-thirds aged 35 to 65, is at or past retirement age. As confirmed by several surveys, another factor is stress, an even more acute concern since the pandemic and politicization of public health.
These staffing losses have only worsened during the pandemic. The Bureau of Labor Statistics reports that, since February 2020, the entire healthcare sector (including public health) has lost nearly 500,000 workers. An estimated 20 percent of health care workers have quit. During the pandemic, over 300 public health officials have retired, quit or been forced to resign.
There are some reasons for hope. Medical and nursing school applications have risen during the pandemic. The Covid-19 stimulus package includes $7.4 billion for training and recruiting public health workers. Still, there is much more to be done. The de Beaumont Foundation recently estimated that state and local public health agencies need 80,000 additional full-time employees to restore our public health system.
Saving the Public Health System
The betrayal of our national defense shield—the one that protects from fatal diseases, toxins and contagions, that ensures our survival as a nation—did not begin during the pandemic. The defunding of public health programs has been underway for decades with our muted consent or indifference. The cold-blooded political war on public health will merely accelerate the system’s collapse.
What will this collapse look like? Fewer and fewer Americans living in communities with adequate public health services (already less than half). Diminished programs like disease screening, maternal health, child vaccinations, opioid control and food inspections. Neglected social factors. Higher treatment costs. Greater health disparities. A disabled pandemic defense capability.
To shift our emphasis from treatment to prevention and rearm our nation, states and localities for future health crises, we must redesign and rebuild the US public health system. This pandemic affords us a unique opportunity to do so. Will we?