Appendix D

Financing State and Local Public Health Departments: A Problem of Chronic Illness

Samuel Y. Sessions, MD, JD

INTRODUCTION

A commentary on the field of public health finance in 2004 begins with these sobering observations:

Public health finance is practiced in thousands of public- and private-sector settings every day, yet has little practical or theoretical literature, hardly any research or teaching, and no systematic means for public health leaders, elected officials, and finance professionals to communicate about innovations and best practices.…

Public health finance … is an embryonic field that lacks basic concepts, data, measures, and practice guidelines, as well as terminological, conceptual, and methodological consensus. (Moulton et al., 2004, p. 377)

The field has advanced in the intervening 7 years, but it remains at a relatively early stage of development. In the meantime, the financial challenges faced by virtually all government functions, including public health, have grown substantially. The fiscal posture of federal, state, and local governments has deteriorated as a result of the worldwide economic downturn. Pressure to reduce spending at all levels of government, and for any purpose, is severe. Powerful long-term trends in public finance attributable to demographics and fundamental changes in the economy have had no meaningful response. Even if the economy experiences a more robust recovery in the near term than is now anticipated, these structural problems will persist



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Appendix D Financing State and Local Public Health Departments: A Problem of Chronic Illness Samuel Y. Sessions, MD, JD INTRODUCTION A commentary on the field of public health finance in 2004 begins with these sobering observations: Public health finance is practiced in thousands of public- and pri- vate-sector settings every day, yet has little practical or theoretical literature, hardly any research or teaching, and no systematic means for public health leaders, elected officials, and finance professionals to communicate about innovations and best practices.… Public health finance … is an embryonic field that lacks basic concepts, data, measures, and practice guidelines, as well as termi- nological, conceptual, and methodological consensus. (Moulton et al., 2004, p. 377) The field has advanced in the intervening 7 years, but it remains at a relatively early stage of development. In the meantime, the financial chal- lenges faced by virtually all government functions, including public health, have grown substantially. The fiscal posture of federal, state, and local gov- ernments has deteriorated as a result of the worldwide economic downturn. Pressure to reduce spending at all levels of government, and for any purpose, is severe. Powerful long-term trends in public finance attributable to demo- graphics and fundamental changes in the economy have had no meaningful response. Even if the economy experiences a more robust recovery in the near term than is now anticipated, these structural problems will persist 205

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206 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE unless corrective action is taken. The prospects for the future look no better and may well be worse. Thus, while public health finance has suffered from neglect for years (Honoré et al., 2004), the need for greater attention to financial consider- ations in public health has become especially urgent. Previous studies have called for increased funding for public health, but accomplishing this goal, or merely ensuring greater stability for funding at existing levels, requires negotiating a formidable array of political, legal, and other challenges. This paper analyzes these challenges and describes both a general strategy and more specific proposals designed to meet them. This paper is commissioned by the Institute of Medicine (IOM) Committee on Public Health Strategies to Improve Health and is intended to assist the committee in developing recommendations for funding state and local public health systems after health care reform. The essay from 2004 quoted earlier describes a framework for public health finance that divides it into four possible categories, based on the source and use of funds, and whether they are controlled by government or the private sector. In the first, most traditional category, government con- trols both the sources (e.g., taxes) and uses (e.g., spending by state and local public health departments) of funds. In the second, government controls the sources, but the private sector controls the uses. This category consists primarily of tax expenditures. The third category involves private control of sources and government control of uses, as in the case of charitable services required of nonprofit hospitals to qualify for nonprofit tax status. In the final category, private entities control both the sources and uses of funds. Health promotion benefits provided by businesses to their employees but not due to tax savings are an example of this category (Patient Protection and Affordable Care Act (ACA), Public Law PL 111-148, as amended by Health Care and Education Reconciliation Act of 2010, PL 111-52. 111th Cong., 2nd Sess., 2010). Funding of state and local public health departments, the committee’s concern, lies primarily within the first of these four categories of public health finance. For this reason, and because of its intrinsic importance, this paper focuses primarily though not exclusively on this category. State and local health department spending is financed in part by the federal govern- ment (including under the ACA [PL 111-52]), and local health department spending is in turn financed in part by state governments. This paper thus discusses public health finance at all three levels of U.S. government. It ex- amines how funding of public health is and should be allocated within the federal system, and how it can be stabilized and, if possible, increased at a time when there are strong pressures in the opposite direction. Governments at all three levels and in all regions of the country face similar problems: revenue bases that are eroding (Brunori, 2007a,b) and

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207 APPENDIX D long-term commitments, such as state and local pension obligations and Medicare, that are growing (CBO, 2011b; Davey, 2011; Elliott, 2010; Novy-Marx and Rauh, 2011; Paletta, 2011; TFAH, 2009; The Economist, 2011b,c; The New York Times, 2011a). There is a limited number of ways in which public health can increase the amount and improve the stability of its financing by government: identifying or expanding revenue sources that can be dedicated to public health, increasing public health’s share of general government revenues, increasing or stabilizing the total amount of government revenues, or some combination of these options. In addition to agencies of the federal government, the 50 states and the District of Columbia, there are approximately 2,800 local health depart- ments, some serving fewer than 1,000 residents, others as many as 8 million (Mays et al., 2009). For this and other reasons, much less is known than would be desirable about the financial and economic characteristics of pub- lic health systems (Hook and Boles, 2011). From the standpoint of funding rather than provision of services, however, there are important similarities in the fundamental problems confronted at all levels of government and in the options available to them. These similarities make it possible to reach some general conclusions regarding the financing of state and local health departments despite their wide variety in size, services provided, and other circumstances. As an early draft of this paper was being written, Congress and the White House were engaged in budget negotiations concerning how to achieve large budgetary savings as part of an agreement to raise the federal debt ceiling and avoid default by the United States on its debt (Sack, 2011). The state of Minnesota was undergoing a government shutdown as a result of a standoff between its governor and legislature over how to close a $5 billion state budget deficit (Mays et al., 2009). The city of Detroit had de- cided to close half of its schools, and Camden, New Jersey, laid off half of its police force this year because of budget problems (Appelbaum, 2011). Legislation was enacted in early August 2011 that enabled the federal gov- ernment to avoid technical default, but few economists believe it is sufficient to provide long-term financial stability for the federal government (The New York Times, 2011b), and critics argue that in the near term it will worsen the budgetary position of state and local governments (Sensenig, 2007). Budgetary issues at all levels of government are thus literally headline news to a degree that is rare if not unprecedented in this country. The problems are in many respects decades in the making, and they result from changes in the economy, demographic factors, long-standing political trends, and interactions among them. The challenges that state and local public health agencies face in financing their services are part of and entangled with these broad economic and political developments. Accordingly, they must be taken into account in efforts to address them.

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208 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE This paper is divided into six sections. The first section examines the current status of public health finance in the United States and the limitations of existing data. The second section discusses literature that has emerged in recent years concerning how public health is most effectively financed by government and at which level. The third section describes the budgetary problems afflicting the three levels of U.S. government, that is, the setting within which public health finance must operate, and the fourth section analyzes the forces that account for these problems. The fifth section presents some possible solutions for public health finance. The solutions are not intended to be exhaustive or complete, but they do illustrate a larger strategy that builds upon the previous analysis and which is itself intended as part of the solution. There are many important unanswered questions about the effective- ness and efficiency of public health service delivery (The New York Times, 2011b), including uncertainties in determining the appropriate amount that state and local governments should spend on public health. In view of the difficulty that public health is likely to experience even to maintain spending at current levels, these uncertainties are set aside in the first five parts of the paper, but they are addressed in the sixth section. The principal themes of the paper are summarized in a conclusion. The problems affecting public finance in general, and public health finance in particular, constitute a form of chronic illness at the policy level. They are long in the making, and they will not be quickly solved. Difficulty in funding public health is a symptom, not a diagnosis. Only with an ac- curate diagnosis can the disease be effectively treated. THE CURRENT STATUS OF U.S. PUBLIC HEALTH FINANCE Shortcomings in the current state of knowledge concerning U.S. public health finance are not merely the result of inattention, but they also reflect the complexity of the U.S. federal system and of the field of public health itself. In addition to the federal government, the 50 states, and the District of Columbia, there is a staggering number of local jurisdictions. The Census of Governments prepared by the U.S. Census Bureau every 5 years is compiled from a universe of more than 87,000 local independent governments, includ- ing more than 39,000 state, county, municipal, and township governments and more than 48,000 special-purpose governments (IOM, 1988). The legal powers and jurisdictional boundaries of governmental public health systems are extremely diverse, particularly at the local level, making it difficult to generalize findings across apparently similar jurisdictions (Sensenig, 2007; The New York Times, 2011b). This creates a considerable challenge even to estimating the amount of government public health expenditures. Much of the information needed to do so can be found only in the

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209 APPENDIX D administrative files of these individual entities, which are poorly accessible and are neither prepared nor organized to facilitate comparison with other jurisdictions or tracking of national data. Even if the data were more read- ily available, however, there is no universally accepted definition of “public health” (IOM, 1988). Under one definition, it includes much more than services provided by public health agencies and encompasses such activi- ties as (1) prevention-oriented spending of nonpublic health departments of government (e.g., environmental protection, highway safety agencies), (2) similar spending of health care providers, (3) tax expenditures, and (4) private-sector spending directed at health promotion. While this more expansive definition offers advantages in designing and evaluating public health initiatives (IOM, 2003; Mays et al., 2003), it complicates determining what constitutes public health spending and comparing jurisdictions (CMS, 2011; Moulton et al., 2004). Thus, of seven studies reporting on public health expenditures by selected state and local health departments between 1994 and 2002, no two used the same operational definition to develop or report their findings (Moulton et al., 2004). Not only is information concerning the amount of public health spend- ing heterogeneous, there is also uncertainty about the effectiveness of public health practices, and therefore about what level of spending is appropriate (CMS, 2011). In addition, according to the National Health Expenditure Accounts (NHEA), probably the most widely cited measure of health-related spending, government spending on public health as a percentage of total health expenditures appears to be relatively stable. In the late 1990s it re- turned to a peak reached in the early 1970s. It declined only slightly during the last decade, from 3.2 percent of total health spending in 2000 to 3.1 percent, or $77.2 billion, in 2009 (Frist, 2002; TFAH, 2008b). All of these considerations suggest that the question of how to increase and provide stability to public health finance may be premature, if not wholly unwarranted. There are several reasons why it is not. First, there is a consensus among public health experts that U.S. public health spending is too low, as well as statistical analyses supporting this view (TFAH, 2008b). A study by the Trust for America’s Health (TFAH) found that adequate funding of public health at the federal, state, and local levels would require an additional $20 billion annually (2009). Other estimates of the needed increase in the amount of public health spending have also been offered (Levi et al., 2007). The TFAH estimate will be used in this paper as a benchmark for discussion. This facilitates comparison with current public health spending and assessment of the economic and political challenges involved in maintaining or increasing it. It is examined more critically in the final section of the paper, however, along with related issues concerning evaluation of the appropriate level of spending on public health. Second, per capita public health spending is both highly variable across

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210 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE jurisdictions and is often quite low, in some cases extremely low, especially when compared with spending on personal health care. This is true regard- less of whether the source of funds is federal, state, or local, separately or in combination. According to one study, federal public health spending per capita through the U.S. Centers for Disease Control and Prevention (CDC) in fiscal year 2009 averaged $19.23, but it ranged from a low of $13.33 in Virginia to a high of $58.65 in Alaska. Median state public health spending in fiscal years 2008-2009 was $28.92 per person, ranging from $3.55 in Nevada to $169.92 per person in Hawaii (TFAH, 2009). A study published in 2009 reported local public health agency spending by quintile, with aver- age per capita spending for the middle quintile of $29.89. Average spending in the lowest quintile, however, was $7.68, compared with $101.86 for the highest quintile, a ratio of over 13 (Mays and Smith, 2009). A survey of 685 local health officials by Baum and colleagues in 2008 and 2009 showed av- erage per capita local health department expenditures of $88.02, but with an almost astonishingly broad range, from $.97 to $1,671 (Baum et al., 2011). These broad ranges are probably skewed as a result of the fact that public health agencies with the highest spending also appear to provide a wider scope of clinical preventive services and medical treatment com- pared with lower-spending jurisdictions (Honoré et al., 2004). Even with this qualification, however, the enormous variation in spending levels, and especially the lowest amounts reported, almost certainly mean that public health spending is insufficient in many jurisdictions. These jurisdictions need to know how to increase the funding of their public health departments even if others may not. Third, as discussed in the third section of this paper, the trends for both the revenue bases and spending of government at all levels have been and remain strongly unfavorable. Policy inertia is thus much more likely to lead to a reduction than an increase in public health spending. Very few jurisdic- tions are immune from these trends, and they are in addition to risks posed by shorter-term fluctuations in the economy, some severe, such as those recently experienced by state and local governments (Sack, 2011). Finally, research has been conducted in recent years examining financial characteristics of public health systems and their impact on performance. While this research is limited and preliminary, and has been conducted by a relatively small group of investigators, it is internally consistent and a useful contribution to the understanding of public health finance. It is discussed in the next section of this paper. FINANCE AND PUBLIC HEALTH SYSTEM PERFORMANCE TFAH has reported considerable data on the extent of federal funding for state health departments by CDC and the Health Resources and Ser-

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211 APPENDIX D vices Administration, as well as various health outcomes by state. However, the report did not systematically correlate these variables (TFAH, 2009). State public health agencies may be independent of other agencies (“stand- alone”), part of larger agencies such as a state department of health services (“umbrella”), or independent but also charged with performing functions other than public health, such as Medicaid administration and health insur- ance regulation (“mixed”). TFAH noted a previous finding that these dif- ferences in organizational structure did not seem to play a significant role in the amount of state public health funding (TFAH, 2009). Other research focusing on local public health departments, however, has assessed the relationship between the sources of funding for public health services and performance. These studies have relied primarily on the measures of 10 essential public health services of the National Public Health Performance Standards Program launched in 2002 (CDC, 2010; Moulton et al., 2004). Not surprisingly, they find that public health performance im- proves with increased funding, but they also indicate that both the nature and the source of funding, federal, state, or local, matters. The survey of local public health department officials by Baum and colleagues provides a baseline for the sources of funds for local health de- partments. These results are summarized in Table D-1. (The numbers have been rounded and some details omitted.) Eighty-six percent of the health TABLE D-1 Major Sources of Funds for Local Health Departments Local Governance State Governance Revenues by Source, % Total (n = 517) (n = 91) Local City/town 7 8 0.4 County 19 20 8 (Total local) (26) (28) (9) 20 18 32 State Federal Pass-through 17 17 13 Medicaid 10 8 25 Medicare 5 5 3 Direct 2 2 2 (Total federal) (34) (33) (43) Fees Patient 4 4 2 Regulatory 7 8 2 1 2 0.5 Private Foundations 1 1 0.5 Private Insurance 7 7 6 Other SOURCE: Adapted from Baum et al., 2011.

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212 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE departments surveyed were governed at the local level, and 14 percent at the state level. As Table D-1 shows, there were obvious differences between the two types of departments in their reliance on local versus state revenues, and state-governed departments received more federal funds as a result of greater Medicaid funding. This is probably the result of differences in services in the two cases, but this is not reported by the authors. Results, not included in the table, were also reported for local health departments serving small (<50,000), medium (50,000-499,999) and large (500,000 or more) populations. Overall percentages of revenues from the federal government, the states, and local sources did not vary dramatically with population size, although as population increased the percentage of state revenues grew (from 20 percent for the smallest to 24 percent for the largest departments), and the internal breakdown of federal revenues changed. The largest jurisdictions received more direct federal funding (6 percent) compared with the smallest jurisdictions (1 percent) but less rev- enue from Medicaid (7 percent vs. 12 percent). Several studies now support the conclusion that the most effective form of public health spending is local health department spending. Mays and colleagues found the strongest predictor of public health system per- formance was the size of the population, with larger size correlated with better performance on 7 of the 10 essential public health services. The most consistent predictor of performance, however, was local health department spending, which was positively correlated with all 10 services. Increased federal spending was associated with improved performance for only 5 of the 10 services, and generally had a smaller effect in each case than local spending. This study estimated that a $100 per-capita increase in local pub- lic health department spending would raise performance scores by up to 7.6 percent (Mays et al., 2006). More recently, Mays and Smith (2011) reported the results of a lon- gitudinal study finding that mortality rates from preventable causes of death, including infant mortality and deaths due to cardiovascular disease, diabetes, and cancer, fell between 1.1 and 6.9 percent for each 10 percent increase in local public health spending. All-cause mortality and deaths from influenza also were negatively correlated with increased local public health spending, while deaths from control conditions such as Alzheimer’s disease did not (Mays and Smith, 2011). Similarly, Erwin and colleagues found that increases in local health department expenditures were significantly associated with decreases with infectious disease morbidity at the state level (Erwin et al., 2011). Likewise, in a 2004 study by Mays and colleagues local public health agency spending emerged as a significant but relatively modest predictor of performance for 9 of the 10 essential services. Federal public health spending was associated with increased levels of performance for 7 of the 10 services

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213 APPENDIX D and state spending with only 2 of 10 (Mays et al., 2004b). The authors estimated that a $10 increase in per capita local public health spending was associated with increases in performance of 1.5 to 3.1 percentage points, and the same increase in federal spending would result in increases in per- formance ranging from 0.1 to 0.3 percentage points. These modest effects might be compared with total per capita public health spending, recently estimated as $120 (TFAH, 2009), but one should be cautious about attribut- ing too much precision to either side of the comparison. Furthermore, the finding that local health spending is more effective than spending at the federal or state level is consistent with an earlier study by Mays and Smith showing a strong positive correlation between public health system performance and local tax revenues. According to this study, local public health systems whose performance was above the mean for the population derived 65 percent of their revenues from taxes, 11 percent from state and federal funding, and 23 percent from other sources. By contrast, taxes made up only 28 percent of funding for those agencies whose perfor- mance was below the mean; these agencies received 31 percent of revenues from the state and federal government and 41 percent from other sources (Honoré et al., 2004). This comports also with research indicating that de- centralized public health agencies and agencies governed by a local board of health were significantly less likely to experience reductions in per capita spending compared with their counterparts (Levi et al., 2007). Finally, Bernet found a significant positive correlation between increases in local public health revenues in Missouri and increases in per capita state and federal revenues devoted to public health. For each $1 increase in per capita state and federal revenues local public health agencies increased their own funding by $.50. Rather than using federal and state revenues as a substitute for local public health spending, it appears that these local jurisdictions increased it (Bernet, 2007). In short, local public health funding appears to be superior to federal funding, which appears to be superior to state funding, but the evidence in favor of the superiority of local funding is the strongest. In addition, there is evidence that greater reliance on taxes to finance public health is corre- lated with better outcomes, and that greater local control is associated with greater funding stability. While the direction of the causal relationship is unclear, the conclusion that local revenues are best for local public health services is also consistent with scholarship in tax policy about local govern- ment services in general (Brunori, 2007a). Consequently, it seems reasonable to believe that marginal public health spending should be directed to local public health departments, and that they should attempt to support their own spending locally, as much as possible. The study by Bernet indicates further that local public health spending is complementary to federal spend- ing rather than competitive with it.

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214 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE The goals of public health finance thus should be to match public health spending with the appropriate level of government, to increase it when justi- fied programmatically, and to stabilize it against the powerful forces acting to reduce it. In the abstract, this means targeting funding to local public health departments, which appear to be able to use it most successfully. The research is much too limited and public health spending at the federal and state levels is much too diverse, however, to conclude that increases in the latter could not be well spent and are not needed in their own right. In addition, if important public health needs are not and cannot be met at the local level, then the state and federal governments should either attempt to supplement local funding or fill the gaps themselves. To some extent this can be accomplished by reallocating existing funds, but as noted previously the budgetary pressures at all levels of government mean that the absence of policy changes favors reduction of spending on public health, not stabil- ity (Cooper, 2011). Federal and state governments must therefore act to protect their own spending on public health regardless of what happens at the local level. THE BUDGETARY AND LEGAL SETTING FOR PUBLIC HEALTH FINANCE In fiscal year 2008, the last year before the recession significantly af- fected the federal budget, total federal revenues were $2.5 trillion, or 17.7 percent of GDP (Tax Policy Center, 2008). In 2008 state and local govern- ment revenues, net of transfers from the federal government, were about $2.2 trillion (Barnett, 2011; U.S. Government Revenue, 2011). Although these are revenue rather than spending figures and are not precisely compa- rable, they are sufficient to illustrate the magnitude of public health spending relative to all of government. Using the NHEA estimate of $72.9 billion in public health spending in 2008 (CMS, 2012), it was the equivalent of about 1.6 percent of U.S. government revenues at all levels in that year. The good news from a political standpoint is that even if public health spending is increased in keeping with recent public health expert recom- mendations, it would remain a relatively small share of total government outlays. In addition, much of the intellectual case that public health has to make for itself is very strong. The bad news is that every dollar of govern- ment spending and revenues is now fiercely contested. Generating an addi- tional $20 billion of spending on public health each year in accordance with the TFAH recommendation, for example, will require not merely creativity, but also a persistent strategy designed to address a complex set of budget- ary, legal, economic, and political considerations that both accounts for the existing problems and makes their solutions extraordinarily difficult. This section of the paper discusses the budgetary and legal issues involved, while the fourth section focuses on political and economic concerns.

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215 APPENDIX D Historically and under the Constitution, federal, state, and local gov- ernments have different patterns of and authority to tax as well as different spending responsibilities. Despite these differences all three levels of govern- ment confront somewhat similar, and quite serious, problems in providing for their long-term financial stability. The flow of government funds from one level to another (generally downward) means that these problems are interdependent. Many of the problems on the spending side of the ledger are relatively widely known, but other, less well-publicized problems con- cerning governments’ ability to raise revenue are no less important. In both academic literature and the media, the lower the level of government, the less attention these problems tend to receive. The discussion below will therefore proceed in the opposite order. Local Governments Both local and state governments face long-term problems in funding employee pensions and retiree health benefits (GAO, 2010; The Economist, 2011a; The New York Times, 2011a). Otherwise, except for spending related to health care, local government spending needs—for such basic services as schools, fire and police department protection, and infrastructure development—vary more or less with population size and are relatively consistent over time. The ability to meet these needs, however, is widely variable from one ju- risdiction to another and is obviously subject to fluctuations in the economy (Dillion, 2011). Infrastructure spending has lagged, creating a budgetary overhang. Local governments depend heavily on transfers from states and the federal government, which face their own severe budgetary challenges. There is a consensus among local public finance experts that local govern- ment operations should be funded to the extent possible with local sources of revenues, and the study by Mays and Smith (2011) indicates that this may be true for public health in particular. All of these considerations point to the conclusion that in the years ahead local governments will need to generate as dependable a source of revenues on their own as is possible. For legal and economic reasons, however, local governments have considerably less flexibility in achieving this goal than the federal or state governments, even if they can muster the political will to do so. At present, intergovernmental transfers and property taxes are by far the dominant source of local government revenues. In 2006, local govern- ments received about 38 percent of total revenues from intergovernmental transfers: about 34 percent from state governments and 4 percent from the federal government. State transfers to local governments have remained relatively stable as a percentage of total local government revenues, while federal transfers decreased from a high of about 10 percent in the 1970s to current levels in the early 1990s and then stabilized (Brunori, 2007a;

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242 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE amount spent on health as the budget framework, including medical care, public health, and health-related research. If, however, the United States spends too much on medical care, as many believe it does, then that frame- work is also distorted. Adjusting for the distortion would in turn require establishing how much ideally should be spent on health care. This presents both the same problem as the proposal of comparing public health spend- ing to GDP and additional complexities of its own. Similar issues arise for state and local budgets, and hence bottom-up approaches, since all spending involves the opportunity costs of other uses of funds, and there is no limit to the possible competing demands. Bottom-up estimates of what spending is needed on public health also require an assessment of how effective public health spending is, which in turn requires the choice of a metric to make that assessment. Metrics em- ployed by bottom-up research include comparative effectiveness measures such as quality-adjusted life-years (QALYs) (Kindig and Mullahy, 2010), performance of the 10 essential public health services (Mays et al., 2006), and others (Mays and Smith, 2011). None is free of problems (Zimmerman, 2011), and each may have appropriate uses, depending on the context and, as a practical matter, simple availability of the data. For example, QALYs may facilitate comparison with health care spending, and so might be more useful to the U.S. Congress, whereas performance of essential public health services may be more useful to local public health officials. As a practical matter, simple availability of the data may dictate the choice until better standardization of databases is achieved. The multiplicity of standards, however, further complicates the conceptual problems. In any case, no methodology for estimating the amount of public health spending needed in the United States has yet gained general acceptance. Moreover, even if accurate, the existing estimates are not well suited to budget planning, in that they provide aggregate numbers and not an esti- mated cost of specific proposals, whether of new or existing public health activities, designed to achieve identified public health goals. Public health finance researchers have in fact recognized that at present there is a shortage of evidence concerning the value of specific investments in public health that would support such budgetary proposals (Mays and Smith, 2011). Indeed, one group of scholars has gone so far as to suggest that the issue “whether public health performance is correlated with improved community health” is itself an open question (Scutchfield et al., 2009, p. 270). Public health finance researchers thus face both theoretical and practi- cal difficulties in determining how much the United States should spend on public health. This also presents obvious problems in making the political case for devoting additional resources to public health. On the other hand, there are important differences between the academic research agenda and the wide variety of political communities. This means that their approaches

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243 APPENDIX D to the questions are also different and, in the case of the political process, variable. There is an overlap between the research agenda for public health finance and the informational needs of political institutions, but they are not identical. Progress on the research agenda will benefit the political process, but it will not necessarily drive it. The analysis of the question thus differs depending on the setting. The Research Agenda Although it is something of an idealization, public health finance re- searchers can be considered a single academic community, whose goal is to develop a consensus on the most rationally defensible answer to the ques- tion of how much public health spending is needed, supported by the best possible evidence base. The sooner that consensus is arrived at (if ever), the better, but there is no deadline and the timetable is indefinite. Bottom-up and top-down approaches perform different functions in striving to achieve that goal. Neither the bottom-up nor top-down approaches can avoid the concep- tual problems noted above. Bottom-up approaches encounter the specific problem of choice of metrics to a greater extent than top-down ones. Unlike top-down approaches, however, bottom-up research generates information to support specific evidence-based interventions in public health. These data are also potentially useful for decision makers at all levels of govern- ment—local, state, and national—again unlike top-down estimates. In the process, the data constitute small components of an overall estimate, and are more readily converted into budget proposals than top-down estimates. The conduct of bottom-up research will also help motivate efforts to con- solidate how information is recorded and made available, and targeting the goal of an aggregate estimate provides an incentive to achieve agreement, or as much as is possible, on the relevant metric or metrics. It may be worth noting in this context that despite their disadvantages, QALYs facilitate comparison of public health interventions with medical care. QALYs fail to capture all of the relevant value achieved through im- proved health (Gostin, 2008). To the extent, however, that public health advocates wish to make the policy and political argument that public and population measures would reduce medical costs, and therefore be cost- effective in that sense, this may provide a reason for greater use of QALYs in public health finance research in appropriate cases. A similar argument can be made in favor of conducting research in terms of other health outcomes such as morbidity and mortality. The 10 essential public health services, on the other hand, are effectively process measures and may be less read- ily suited to arguments comparing the value of public health interventions with medical care.

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244 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE Bottom-up research also has to assign priorities. These presumably include the feasibility of the research. As a policy matter, however, it may be desirable to increase research on local jurisdictions with very low per capita spending on public health. To the extent that this research bears out the hypothesis that such jurisdictions have significant and urgent needs for increased funding, it could be used to support a dedicated financing mecha- nism to provide that funding, as discussed in the fifth section of this paper. One possibility along these lines is suggested by the model public health systems proposal, analogous to the Department of Education’s “Race to the Top” program, also outlined in section five. Per capita spending in the model public health systems serving populations of various sizes could be used to set thresholds for minimum spending in jurisdictions of similar size. Top-down estimates are not as well suited to budget planning as bottom- up estimates, but they can serve a broader hortatory or aspirational function in the policy and political processes. The methodology used to generate the existing estimates thus far can be fairly easily criticized, however, and ef- forts should be made to improve them. There may be a limit to the amount of precision and reliability that can be achieved, but progress toward that end will also enable top-down estimates better to perform a second, more academic function. That is, top-down and bottom-up approaches have a dialectical relationship, in that top-down estimates serve as guidelines for assessing the state of development of fine-grained research. The larger the gap between top-down and bottom-up estimates, the more that remains to be done on bottom-up research (assuming that the top-down estimate is generally accurate). Because top-down estimates are developed not only for the amounts ac- tually spent on public health, but also for the amounts that should be spent, this benchmark function of top-down estimates will remain relevant even if work on bottom-up estimates has reached a very high level. At present, the gap between top-down estimates and any estimates based on bottom-up research is likely to be very large. Ideally, in the long run, the two types of estimates should converge, but they would continue to be checks on each other. Thus, both top-down and bottom-up approaches are and should remain useful for academic purposes. The Political Arena By contrast with a theoretically unified research community, there is an enormous number of overlapping political communities. They include not only every political jurisdiction in the country, at every level of government, but countless subpopulations within each jurisdiction, such as legislatures, legislative committees, executive branch officials and agencies, and voters, which in turn have various political alliances and predilections. What will

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245 APPENDIX D count as sufficient evidence that a given amount should be spent on public health, and how public health is defined for that purpose, will depend on these predispositions. Democrats will differ in this respect from both Repub- licans and independents. It will also depend on the time and circumstances, even for the same individual or individuals. The political and economic environment in 2012 is different from that in 1965, or even 2008. Political communities are also presented with specific questions, to be answered at a more or less specific time. For example, legislators may be asked to vote on an annual appropriations bill or instead for a trust fund financed with an earmarked tax. A local public health board has to decide how to allocate its budget at a particular point in time with the information it has available. Elections occur on scheduled dates. In the current era of political gridlock, legislative action can be deferred seemingly indefinitely, but there are practical consequences of delay. The upshot of considerations such as these is there is no single or un- changing standard employed in politics to assess how much spending is needed on public health, even in theory. The Prevention and Public Health Fund included in the ACA can serve as an example. It provides for substantial increases in public health spending without specifying details, and without a dedicated financing mechanism. Members of Congress who voted in favor of the ACA, and thus the Fund, are doubtless more favorably disposed toward government spending, and spending on public health in particular, than those who voted against it. It seems likely that they would, and probably should, have been less inclined to vote for the Fund if it had provided for permanent appropriations financed with an earmarked tax (Patashnik, 2000). To the extent that bottom-up evidence in favor of public health spending is underdeveloped, and given the large amounts involved, a vote in favor of the Fund thus would appear to be supported by top-down rather than bottom-up evidence. Both as an explanation and a justification, this seems consistent both with the political inclinations of its supporters and the substantive nature of the Fund. This example concerns policy making for the federal government, but similar factors would apply analogously to decisions at the state and local level. Politically, more evidence in favor of a given position is always better. Both top-down and bottom-up estimates can be useful depending on the context. Thus, both top-down and bottom-up approaches have a place in politics as well as in academics. In the political arena, however, this is not because of an attempt to converge on a single answer to the question of the appropriate amount of public health spending by comparing top-down with bottom-up estimates, but for practical, rhetorical purposes as well as in the interest of good policy. Nevertheless, it does result in a substantial overlap in the agendas for public health finance researchers in the political and academic contexts.

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246 FOR THE PUBLIC’S HEALTH: INVESTING IN A HEALTHIER FUTURE Developing the public health finance database will take a substantial amount of time, even if efforts to do so increase markedly over present lev- els. As discussed in section five, laying the political groundwork for political support for increased public health spending will also require a considerable investment of time. As a result, and somewhat fortuitously, these efforts can be thought of as on somewhat similar timetables, and so can to some extent proceed in parallel. It might be argued that in the meantime public health policy should be put on hold, or even that in the absence of compelling evidence in favor of public health interventions there should be no public health spending at all. There are presumably very few policy decisions, however, especially bud- getary decisions, that are supported by truly overwhelming and irrefutable evidence. Decision makers therefore have no alternative to making choices in the face of uncertainty (Kindig and Mullahy, 2010). On the other hand, there is no room for complacency. Asking voters or legislators to increase taxes to support new public health activities, or even to devote existing revenues to public health rather than alternative uses (including tax cuts), is challenging enough. Uncertainty about the amount of funding that is and can be put to effective use in public health makes that challenge even more formidable. The fierce competition for public funds, the distressing condition of the economy now and for the foreseeable future, and pressure to reduce government spending all dictate that finance be assigned a high priority in the public health research agenda. This research itself requires funding. Several commentators have argued recently that public health interventions should be included in comparative effectiveness, or patient-centered outcomes, research funded by the ACA and, earlier, the American Recovery and Reinvestment Act (Kindig and Mullahy, 2010; Scutchfield et al., 2009). In view of the need to improve the evidence base, and thus the political case, for public health finance, these arguments deserve urgent and close attention. CONCLUSIONS The financial challenges faced by public health cannot be dealt with adequately in isolation from and ignorance of broader challenges to public finance. It is unlikely that state and local health departments will be able to obtain secure and adequate funding if government finance more generally is collapsing. It will therefore be necessary not only to pursue funding op- tions targeted specifically to public health, but also for public health leaders to work with others in addressing these broader public finance concerns. Public health leaders should also work to pursue funding options de- signed specifically to support public health, and to increase funding of public health out of whatever revenues are available. To do so effectively they must

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247 APPENDIX D understand the constraints involved at all three levels of government and how they relate to one another. They must be able to convince voters and legislators of the merits of the public health activities that the revenues in question will finance. They should coordinate their efforts for reasons of both politics and policy. They should assign a high, even very high, priority to research in public health finance. The severe pressures on public health finance for the foreseeable future make all of these elements of a compre- hensive strategy imperative now, if they were not already. Both the broader threats to public finance and the difficulties more spe- cific to public health finance are long in the making. The demographic and economic changes, and the changes in the mission of public health caused by the increased emphasis on chronic disease and upstream determinants of health, are also long-term in nature. The powerful influence of the antitax movement is partly the result of its having followed a patient, long-term strategy whose beginnings can be traced to the 1950s, with periodic suc- cesses that were first consolidated and then built upon. It has been an enor- mously well-orchestrated and well-financed effort that has played into and contributed to changes in the economy as well as Americans’ skepticism about government. It is unlikely that public health can match the financial resources of the antitax movement even if it joins forces with other policy communities. It does, however, need to match that movement’s focus, coordination, and long-term perspective. The intellectual case for much of what public health wishes to accomplish is strong, even overwhelming, but public health must also make this case in a way that is more compelling to the average voter than it has in recent years. REFERENCES Aaron, H. J. 2010. The midterm elections: High stakes for health policy. New England Journal of Medicine 363(18):1685-1687. Appelbaum, B. 2011 (August 27). Fed chief says politics hurt markets and nation: Bernanke suggests fiscal process is broken in U.S. Online. The New York Times, p. A1. Barnett, J. L. 2011. State and Local Government Finances Summary: 2008. Governments Division Brief. Washington, DC: U.S. Census Bureau. Baum, N. M., C. Desroches, E. G. Campbell, and S. D. Goold. 2011. Resource allocation in public health practice: A national survey of local public health officials. Journal of Public Health Management & Practice 17(3):265-274. Bernet, P. M. 2007. Local public health agency funding: Money begets money. Journal of Public Health Management & Practice 13(2):188-193. Bittman, M. July 23, 2011. Bad food? Tax it, and subsidize vegetables. The New York Times, SR1. Blendon, R. J., J. M. Benson, G. K. SteelFisher, and J. M. Connolly. 2010. Americans’ conflict- ing views about the public health system, and how to shore up support. Health Affairs 29(11):2033-2040.

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