Securing the Long-Term Sustainability of State and Local Health Departments Policy Statement

Related Policies
APHA policy statement 51-05: Financial support of public health activities1
APHA policy statement 61-01: Financing of high quality health services for the aged2
APHA policy statement 64-02: Increase in federal grants for general public health services3
APHA policy statement 79-08: Urgent crisis in public hospitals4
APHA policy statement 94-14: Federal and state financial support for training of public health professionals5
APHA policy statement 2003-4: Protecting essential public health functions amidst state economic downturns6
APHA policy statement 2006-06: Conduct research to build an evidence-base of effective community health assessment practice7
APHA policy statement 2003-19: Support for WIC and child nutrition programs8
APHA policy statement 2003-23: Strengthening the fiscal viability and independence of public health while responding to terrorism9
APHA policy statement 2004-03: Workplace Violence prevention—increased funding for intervention research, training, and establishment of an enforceable OSHA standard10
APHA policy statement 2009-11: Public health’s critical role in health reform in the United States11

Throughout the last century, the nation’s public health system achieved notable improvements in population health, reducing illness and death from an array of infectious and environmental diseases and increasing Americans’ longevity and quality of life. At the core of America’s public health system and at the vanguard in the battle to improve the population’s health are the nation’s state and local public health agencies. These agencies develop and promote public health policies as well as implement them. Local and state health departments protect the health of communities, providing resources, monitoring performance, and providing technical assistance and surveillance functions. Continued progress in securing the health of America’s populace will hinge on the ability of our frontline agencies to develop and carry through broad-based, multisectoral health interventions to address both old and emerging threats to health security.^12–16

In its landmark 1988 report, the Institute of Medicine (IOM) characterized the nation’s public health system as being in disarray. The areas of weakness identified by the IOM developed in significant part because of the inadequacy of financial resources devoted to the system.¹⁷ This financial neglect contributed to the erosion of the nation’s public health infrastructure and hampered efforts to adapt to the changing requirements of securing and enhancing the public’s health. Further evidence released in the IOM’s 2002 report deepened the understanding of the problems facing public health agencies. This report indicated that in addition to the chronic underfunding for services, other elements, such as the underdevelopment of clear and coordinated plans for the investment of funding, having a limited system for performance measurement and improvement, and possessing insufficient methods for accountability, contribute to the continuing woes of the US public health system.¹⁸ Sufficient, stable funding streams for programmatic activities and the development and maintenance of the public health workforce, service capacity, and information technology base are fundamental to the successful achievement of the aims of public health. It is also essential that the system have not only core funding to support needed services but also the necessary resources to develop the strategic and operational capabilities and processes to optimize results from the resources devoted to public health.

Adequate, sustained funding of state and local health departments, coupled with sufficient human and technical resources, is a socially profitable investment. It will reduce illness, injury, disability, and death rates; moderate the rise in health care costs; and bolster preparedness for emergencies and disasters. Evidence indicates that a relatively small increase in public health expenditures is associated with substantial improvement in health status.^19,20 Research shows that an increase in public health spending of $10 per person in the United States would return $5.60 in savings for every dollar invested.¹⁹ At the programmatic level, studies of the effectiveness of the Centers for Disease Control and Prevention’s (CDC’s) Section 317 immunization grants show that for a $10 increase in per capita funding, a 1.6% increase in overall childhood vaccination rates is gained.31 Similarly, numerous studies at the systems level indicate that increased levels of funding and public health expenditures are associated with improved levels of performance in providing the key functions and services of public health.^21–29 Targeted funding increases that were put in place in the immediate aftermath of the attacks of September 11, 2001, have demonstrated benefits in the areas of focus such as disaster/bioterrorism preparedness and in directly related fields such as epidemiology programs but have shown little to no influence in improving overall system performance.³⁰

Significant returns on investment have also been observed in programs directed at ameliorating the threats of environmental hazards, such as mercury contamination of fresh waters and the fish from them that enter the human food chain.^32,33 The Public Health Foundation estimated that, nationwide, the Environmental Public Health Tracking Program yielded $1.44 in return for every federal dollar invested.³³ Increases in federal funding for programs often serves as seed monies to attract greater funding commitments from other levels of government. A 2007 study indicates that for every $1 increase in federal or state funding, local government raises their own contributions to public health by $0.50.34

Although underfunding is pervasive across the country, state and local health departments in the United States vary considerably in their levels of funding and service capacity. This variance in funding between jurisdictions has increased over time.²⁸ Some agencies are relatively well funded and staffed to manage the routine provision of services; many others are not. These inequalities that exist between jurisdictions in terms of public health funding and capacity present the threat of stimulating disparities in population level health across America’s communities. When considered on a national basis or in the event of an emergency requiring an extraordinary response, it is clear that most state and local public health agencies are chronically and severely underfunded.^13–16

Gaps in public health services and programs exist in both rural and urban health departments. Every jurisdiction within the United States should enjoy access to an array of leadership, protective, preventive, and emergency preparedness/response services.^17,35–39 However, this array is too broad and too complex to be fully supported at the local level by small, rural jurisdictions. Many rural agencies are severely understaffed, offer little in the way of service, and depend on staff that may not have formal public health training.⁴⁰ Responsibility for large geographic areas, even when sparsely populated, also presents a special challenge for rural jurisdictions. Often single jurisdictions must join to develop a population base large enough to support at least some of the needed services. They then must depend on their state’s public health agency to provide other services.

The award of federal grants for preventive services contributes to the geographic variation in public health service. Although all states can apply to the CDC for grant funding for specific programs, not all states will receive awards, because insufficient funds are appropriated for all states to receive funding.¹⁵ As a result, of the ¹³ different CDC grants that offer funding to states in chronic disease prevention and health promotion such as arthritis, cancer prevention, and healthy aging, only 5 grants are available to all states. In addition, the amount each state receives can affect the services states are able to provide. For example, the Healthy Aging grant supports only 12 states.⁴¹ On the whole, the effect of lack of funding for public health appears to be most severe on rural local health departments.

Well-developed guides to the services to be provided by state and local public health agencies are available. These are outlined historically in the Model Standards,³⁵ Ten Essential Public Health Services,³⁶ and the 1988 IOM report, The Future of Public Health.17 More currently, they are provided in the National Public Health Performance Standards⁴² and the proposed Public Health Accreditation Board standards.³⁷ Inherent in each of the iterations of public health practice guidelines is a core belief that proactive steps through prevention-oriented, community-based services are the most effective method to promote the public’s health. Evidence indicates that, with some exceptions, agencies lack the financial and other resources needed to meet appropriate standards for the promotion and protection of the health of their constituents. They are also in many cases unable to provide the level of technical support and leadership needed to properly prepare for, prevent, and mitigate the health aspects of natural and human-made emergencies and disasters.¹⁹ For example, the H1N1 influenza pandemic in 2009 showed the strength of the nation’s public health system but also exposed serious gaps in the ability to deal with public health emergencies.²⁰ New federal funding under the Prevention and Public Health Investment Fund could provide much-needed support in this area.

In addition, state and local health departments frequently play a major role in providing health care delivery services not adequately provided by nongovernmental agencies.^43,44 Public health agencies should ensure access to health care services for all in need of care, and access to all types of needed care. Preventive and primary care services should be strongly emphasized.¹⁷ The expansion of insurance coverage within the population and the increased federal investment in community health centers under health reform legislation should aid public health agencies in their assurance functions.

The public health workforce is facing a growing shortage of key public health workers. This shortage includes public health–trained physicians, nurses, health educators, epidemiologists, biostatisticians, administrators, mental health workers, and environmental health workers. The average age of state public health workers is 47 years and in 2010 more than 50% will be eligible for retirement.⁴⁵ Estimates for the year 2020 indicate that 250,000 more public health workers will be needed to replace loses in the workforce simply because of natural attrition.⁴⁵ As highlighted by the Association of State and Territorial Health Officials (ASTHO), “the public health worker shortage, exacerbated by the current economic downturn, threatens the ability of public health departments to respond to major health threats and maintain essential public health responsibilities.”⁴⁶

Many of the underlying causes for the current and growing shortage of public health professionals are related to the weakness in financial support for public health activities. Budgetary restrictions force numerous needed positions to go unfunded. Among those slots that are opened for recruitment, wage and benefit structures are often not competitive enough to attract applicants that have the education, cultural, and linguistic skills necessary in contemporary public health practice.⁴⁷

To successfully pursue the public health mission within our communities, we need “high-quality and well-educated public health professionals”48p1Increased federal funding is needed in support of both academic- and practice-based educational opportunities for both the current and future public health workforce. Promoting dual training opportunities, which couple public health graduate training with other professional training, such as medicine, nursing, dentistry, and veterinary medicine, are another approach that presents promise in meeting the workforce needs of the nation. Loan repayment programs and university programs that provide financial support for students enrolled in public health degree programs could also bolster the public health ranks.⁴⁵ Provisions of the Patient Protection and Affordable Care Act (PPACA) have significant funding that could be directed toward promoting workforce development as described here.

Information systems are crucial to the pursuit of the public health endeavor. Funding to support the enhancement of such systems is needed to develop the interopertability of information systems for the exchange of health and service data between governmental agencies and with private sector partners, as applicable and appropriate.⁴⁹ This would include field testing of standards and protocols that are developed under section 3021 of PPACA.

To ensure that funds are most effectively distributed and used, both state and local public health jurisdictions should strategically evaluate the environment through a health assessment process. This involves the collection, analysis, and dissemination of information on health to be used to determine public health priorities. States and localities should use the resources of their respective associations (ASTHO and National Association of County and City Health Officials) for assistance in this process. Minimal goals that should be reachable with only modest enhancements to current public health agency services can be found in the decennial Healthy People documents.³⁸

Accurate health assessments can guide agencies in taking action to improve the determinants of health in partnership with other sectors of society. These actions will often require the identification and establishment of appropriate collaborations with a variety of organizations. The objective of such partnerships will be to generate societal conditions that improve health, such as educational opportunities, job opportunities, environmental protection interventions, and so on. Health status benefits to all of society will accrue from these approaches.

Community Health Improvement Plans (CHIP) are an approach that can serve as a basis for establishing shared community goals for planning, integrating, and achieving community health priorities. These plans rely on analysis, action, and measurement.⁵⁰ Identifying a community health problem and addressing it requires bringing community stakeholders together in a coalition, monitoring community-level health indicators, and identifying specific health issues within a community.⁵⁰ CHIPs require analyzing a health issue, assessing community resources, determining who should respond and how, and selecting and using stakeholder-level performance measures together with community-level indicators to assess whether desired outcomes are being achieved.⁵⁰ Local health departments should serve as the coordinator for the development, implementation, and evaluation of CHIPs.

Model health departments do exist in both urban and rural areas. They demonstrate the staffing models and management practices needed to optimize preventive services and respond to emergencies, and they serve to address almost any deficiency in the local health care delivery system.⁵¹ Developing managerial skills in the areas of finance and operations is crucial to the efficient provision of public health services. Assessing the return on investment for programs and services enhances the ability of public health agencies to deliver the greatest benefit to the community. Emerging quality and performance assessment practices offer promise for further improvement in public health practice. The voluntary public health accreditation process represents a significant vehicle to structure public health quality and accountability efforts.

Many accreditation programs and accreditation-like programs are based on the essential public health services, as defined in the National Public Health Performance Standards Program^52,53 and are beginning to show that states with accreditation programs produce health departments better able to respond to current public health issues. The essential public health services, a rubric defined in a 1994 national consensus panel, have served as the basis for measuring the performance of the public health agencies since the inception of the National Public Health Performance Standards Program in 1998. Several studies have validated the performance standards.^52,53

One significant problem in addressing the funding challenge is in defining the minimal and optimal set of services to be provided by state and local public health agencies. All agree that commitment to the health of the public, in principle, is a goal to be pursued by the full range of governmental, voluntary, and private entities. However, there is little consensus on which services can be delivered effectively by only governmental public health agencies.

Setting short-term and long-term service and funding goals is necessary for every state and local jurisdiction, as well as at the federal level. According to the Trust for America’s Health, adequately funding public health would require between $55 billion and $60 billion dollars a year.¹⁹ With current public health budgets totaling approximately $35 billion dollars annually, adequate funding will require a 60% to 70% increase in federal, state, and local revenues.¹⁹

Although the increase in federal funding as part of national health reform is a positive step, obtaining increases in public health funding from state and local governments will be more problematic in the wake of the economic downturn. ASTHO found that 76% of state health departments made cuts to their FY09 budgets during FY2009, and 83% of state health departments were forced to lose staff (either through layoffs or attrition) during FY09 or FY10.54 Thus, if a 60% to 70% increase in funding for state and local health departments is needed, it is not immediately obvious where the money will come from. It certainly must be recognized that all levels of government are currently in a state of financial crisis.

Therefore, if increases in public health funding are to be achieved, there must be serious discussion of the financial responsibilities of each level of government for public health.

The federal government funds the medical care system at almost 29 times more than funding for state or local public health services.¹⁹ Because of the positive linkages between prevention activities associated with state and local public health services, and health care system outcomes and community health status, the federal government may benefit financially more than state or local government from investment in the public health system.

Given these circumstances, it would appear to make most sense to propose that the federal government provide a large proportion of the additional funds needed to upgrade the infrastructure triad of our state and local health departments. In return state and local health departments and those they serve would benefit from improved performance, improved accountability, and improved collaboration with both public sector and private sector health insurers and health care delivery systems. In this scenario, states would be required to maintain current levels of funding (indexed to annual inflation rates) and would be encouraged to increase their funding for supplemental services to meet unique state and local needs. In other words, additional federal funding could not be used to replace current funding. It would be used to provide new or enhanced services. Given the multiplicity of issues to be addressed in this transition, including but not limited to funding for educational programs needed to train people for public health careers, it must be recognized that this requires a long-term and continuing commitment at all levels of the public health system.

Just as there is a need for multisectoral services and interventions to secure the health of our communities, so too is there a need for this same form of multisectoral collaborative efforts in financing the public health system. Collaborative efforts between governmental agencies and private sector partners are a growing feature in the public health sphere. Many of these relationships are with traditional nonprofit partners, but an increasing number are with less traditional nonprofit groups and for-profit organizations. The key element is that from a functional standpoint, these efforts represent innovative supplemental funding mechanisms that bring private sector dollars to work for the public good.

One such project conducted in New Mexico has translated $2,000 per year in state/federal seed money to $80,000 to $100,000 per year in additional funds raised by local Rotary Club members. These funds support community vaccination clinics during school registration periods as well as immunization awareness training for child care and preschool workers. Capacity built through this partnership yielded additional benefit during the H1N1 pandemic because the annual immunization clinics were also able to bolster the network of sites providing the new influenza vaccine (Personal communication with Karen Armitage, MD, New Mexico Department of Health, June 11, 2010).

Therefore, APHA, calls for funding to ensure that adequate public health protections and services are available in every state and locality nationwide. Federal, state, and local governments must work cooperatively to address the gaps in service, workforce issues, and operational inefficiencies. APHA supports the development of mechanisms to enhance the funding of state and local health departments, including the following:

• Development of a national public health financial accounting and reporting system. This system should be transparent, valid, reliable, and uniform. It should be used to facilitate accurate estimates of investments in the public health system. The system should also be used to facilitate the training of the public health workforce in contemporary financial management practices for analyzing revenue and expenditure patterns and the population health outcomes and impacts supported by these resources.
• Formulation of recommendations on federal, state, and local revenue sources required to properly fund the public health mission at the state and local levels.
• Local tax support (including, for example, ad valorem and sales taxes) for public health. The lack of local tax support has created a major gap in potential sources of funding for public health services, particularly because these revenue structures have supported other community-based services for more than a century. Public health departments must ask for more support from these sources.
• Request for authorization of federal funds outlined under the PPACA and subsequent reconciliation legislation, for the provision of public health services, particularly for areas where minimum service standards are not currently being met
• Priority for funds targeted for state and local health departments to assist those agencies to enhance services to meet minimum requirements. Improvements in performance and quality should be measured and validated against a set of accepted standards (such as those developed by Public Health Accreditation Board) that ensure the protection of the public and the promotion of health.

References

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2. American Public Health Association. APHA policy statement 61-01: Financing of high quality health services for the aged; 1961. Available at: hwww.apha.org/advocacy/policy/policysearch/default.htm?id=460. Accessed January 31, 2011.
3. American Public Health Association. APHA policy statement 64-02: Increase in federal grants for general public health services. Washington, DC: American Public Health Association; 1964. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=513. Accessed January 31, 2011.
4. American Public Health Association. APHA policy statement 79-08: Urgent crisis in public hospitals. Washington, DC: American Public Health Association; 1979. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=930. Accessed January 31, 2011.
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6. American Public Health Association. APHA policy statement 2003-4: Protecting essential public health functions amidst state economic downturns. Washington, DC: American Public Health Association; 2003. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=1248. Accessed January 31, 2011.
7. American Public Health Association. APHA policy statement 2006-06: Conduct research to build an evidence-base of effective community health assessment practice. Washington, DC: American Public Health Association; 2006. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1330. Accessed January 31, 2011.
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