American Public Health Association
800 I Street, NW • Washington, DC 20001-3710
(202) 777-APHA • Fax: (202) 777-2534 •

Policy Statement Database

New Search »

Protecting Essential Public Health Functions Amidst State Economic Downturns

Policy Date: 11/18/2003
Policy Number: 20034

The dramatic deterioration of state fiscal conditions is having an adverse effect on core public health functions performed by federal, state and local health agencies. State budget deficits totaled approximately $40 billion in fiscal year 2002 and $50 billion for FY 2003.1 Primarily a result of weakening state revenues—-in fact the worst revenue decline since World War II—-the budget shortfalls are not projected to abate in the near future. The budget deficits now looming over states constitute the largest state budget gaps in half a century. Forty-two states are facing budget deficits totaling $60 billion to $85 billion for FY 2004, which represents 13 percent to 18 percent of state expenditures.2 Health care accounts for more than 25 percent of state budgets and continues to grow as a proportion.1
To close the widening gap between revenues and expenditures, states are reducing spending on a variety of programs and essential services, including many that affect those most in need of assistance. States are: restricting eligibility for health insurance programs, like Medicaid and the State Children’s Health Insurance Program (SCHIP)3; reducing mental health and substance abuse services, child care and income support services that rely on the social service block grant; continuing to use the tobacco settlement funds for non-health related uses; cutting back food programs; and scaling back on essential public health programs. For example, in Los Angeles County, officials closed 11 health centers and four school-based health clinics in 2002.3 Budget reductions adopted or proposed in 22 states would lead to the elimination of Medicaid, SCHIP or related public health insurance coverage for 1.7 million people.4 In addition, these budget deficits threaten the viability of many core public health functions, including surveillance systems used to detect and monitor emerging infections, food safety, intentional and unintentional injuries and chronic diseases.
During this time of unprecedented public awareness about the importance of public health services and increasing pressures on the public health infrastructure to respond to emergencies such as West Nile Virus, Monkeypox and Severe Acute Respiratory Syndrome (SARS), public health resources at the state level remain woefully inadequate. The Institute of Medicine (IOM) reported in the Future of the Public’s Health in the 21st Century that the public health infrastructure has suffered from political neglect. Due to recent unprecedented public and political scrutiny, policymakers and the public have become increasingly aware that the system suffers from: vulnerable and outdated health information systems; an insufficient and inadequately trained workforce; an antiquated laboratory capacity; a lack of real time surveillance; fragmented communications networks; incomplete domestic preparedness and emergency response capabilities; and community access to essential public health services.5
Declines in funding for basic public health services also have a direct impact on funding and staffing for bioterrorism preparedness efforts. In FY 2003, states received more than $900 million in grant money intended to expand preparedness for a biological or chemical terrorist attack.6 This money has helped to improve planning, collaboration, training and technology. However, substantive advances in preparedness are hampered by the challenge of sustaining the financial resources necessary in a time of severe budget constraints. According to a survey of local public health agencies, many indicated they are further behind in bioterrorism preparedness efforts because of increasing drains on other public health resources and the need to support the basic public infrastructure that sustains both systems.7 The General Accounting Office has reported that while the efforts of public health agencies to prepare for a bioterrorist attack have improved the nation’s capacity to respond to major public health threats, gaps in preparedness remain.8
Eliminating dollars for public health programs that prevent infectious and chronic diseases, and cutting health services such as Medicaid that serve those most in need puts countless lives at risk. In times of economic downturn, public health systems and health services are needed more—-not less.
Therefore, the American Public Health Association urges that:
1) States protect essential public health programs and public health infrastructure affecting community health and safety despite the fiscal difficulties they may face;
2) Federal financial support for public health programs financed through public health agencies including the Centers for Disease Control and Prevention and the Health Resources and Services Administration be increased;
3) Funding for terrorism preparedness not preclude or supplant sustained financial support for core public health infrastructure, including an adequate workforce, and programs, since public health preparedness and public health services and programs are fundamentally linked and must be mutually supported in order to protect the health and safety of the public;
4) Congress assist states by enacting legislation to limit the severity of Medicaid cuts, increase the social services block grant, support maternal and child health programs, support the State Children’s Health Insurance Program and other coverage for the uninsured, ensure access to preventive services, protect the Special Supplemental Nutrition Program for Women, Infants and Children, and other federally funded child nutrition programs, such as the national school lunch program, school breakfast program, child and adult program, summer food service program, and the special milk program, and support housing programs;
5) States stem the increasing reliance on tobacco settlement funds for uses other than tobacco control programs and public health programs;
6) States consider other important sources of revenue including increased tobacco and alcohol taxes, maintaining estate taxes, closing corporate tax loopholes, and introducing state income and/or sales taxes where none currently exist;
7) States ensure continued state fund match for federal health dollars for the Medicaid program; and
8) Congress request that the General Accounting Office investigate the impact of state budget cuts on public health programs and bioterrorism preparedness.
1. Carey, Kevin. Center on Budget and Policy Priorities. States cut spending in FY 2002 and FY 2003, Additional cuts are likely unless new revenues are raised. Washington, D.C.; October 22, 2002.
2. Lav, Iris J. and Johnson, Nicholas. Center on Budget and Policy Priorities. State Budget Deficits For Fiscal Year 2004 Are Huge And Growing. Washington, D.C., January 2003.
3. Copley News Service. Grim Reality for L.A.’s Health System. June 26, 2002.
4. Nathanson, Melanie and Ku, Leighton. Center on Budget and Policy Priorities. Proposed State Medicaid Cuts Would Jeopardize Health Insurance Coverage For 1.7 Million People: An Update. March 2003.
5. Institute of Medicine. The Future of the Public’s Health in the 21st Century. November 2002.
6. Public Law No: 108-7. Consolidated Appropriations Resolution FY 2003.
7. Issue Brief, The National Association of County and City Health Officials, Improvements in local health preparedness since September 11, 2001. November 2002.
8. General Accounting Office. Infectious Disease Outbreaks: Bioterrorism Preparedness Efforts Have Improved Public Health Response Capacity, But Gaps Remain. Testimony of Janet Heinrich. April 9, 2003.