Economic Issues Facing the Public Health System
SESSION AUDIO:
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MODERATOR:
Julia Costich, Ph.D., J.D.

PANELISTS:

Paul Erwin, M.D., Dr.P.H.
Resources That May Matter: Changes in Local Health Department Expenditures and Impact on State Health Measures
Co-Investigators: G. Mays, Ph.D., M.P.H., W. Riley, Ph.D.
The research objective for this study was to explore the association between changes in local health department resources and changes in state-level health outcomes. Data sources included the surveys of local health departments (LHDs) by the National Association of County and City Health Officials (NACCHO) and America’s Health Rankings (AHR). Expenditure data from LHDs were aggregated to the state level based on the 1993, 1997, and 2005 NACCHO surveys. Health outcomes tracked annually through AHR were available for the same time periods, and specifically included smoking and obesity prevalence, infectious disease morbidity, infant mortality, and deaths from cardiovascular diseases and cancer. Years of potential life lost (YPLL) was used as an overall measure of premature death. A fixed-effects model (FEM) was used to show the association of changes in expenditures per capita with changes in each of the health outcomes, for 1993, 1997, and 2005. Control variables included measures of socioeconomic status and related measures known to impact or influence health status. Usable data from 37 states were included in the final dataset for analysis. The FEM results showed statistically significant associations between increases in LHD expenditures per capita (aggregated to the state level) and improvements in infectious disease morbidity (t= -3.28, p= 0.002) and improvements in premature death rates (t= -2.73, p= 0.008). These findings add to the small but growing empirical evidence that local public health activity is associated with improved health outcomes. Such evidence can be used to substantiate related findings regarding public health performance improvement and community health status, and to advocate for public health resources. Additional research will be needed to better identify the pathways between health department resources and health outcomes.

Rachel Willard, M.P.H.
Trends in Budget, Workforce and Program Cuts by Local Health Departments
Co-Investigators: C. Leep, M.S., M.P.H., G. Shah, M.Stat., M.S., Ph.D.
This study sought to quantify the impact of the economic recession on the budgets, workforce, and programs of Local Health Departments (LHDs) across the United States. The National Association of County and City Health Officials (NACCHO) conducted two on-line surveys in 2008–2009; the first conducted in December of 2008 using census design, and the second in August 2009 using a nationally representative stratified sample of 990 LHDs.  Trends found in the first two surveys will be compared with a third survey to be conducted in January 2010. Findings of the first two surveys demonstrate that across the country, LHDs experienced substantial reduction in budgets, employees, and public health activities and services. In 2009, 45 percent of LHDs reported cuts in their budget compared to the previous fiscal year; this is up from 27 percent in 2008. Job losses increased; in calendar year 2008 an estimated 7,000 LHD jobs were lost, while 8,000 staff positions were lost over six months in the first half of 2009 (January 1–June 30). In addition to staff lost through layoffs, an additional 12,000 LHD employees were subjected to reduced hours or mandatory furloughs in January–June 2009. From July 2008–June 2009, 55 percent of LHDs made cuts to important public health programs. As of July 2009, only 14 percent of LHDs had received funding from the American Reinvestment and Recovery Act. The findings from this study show that LHDs are severely strained by increasing budget and workforce cuts, to the point that they are being forced to eliminate or reduce vital programs that protect the public’s health. These pressures come even as LHDs are being called upon to take the lead in local H1N1 vaccination campaigns and as the demand for many different services has increased due to adverse economic conditions.

Gulzar Shah, Ph.D., M.S., M.Stat.
The Impact of Economic Downturn on Local Public Health: Digging Deeper for the Nuggets Through Qualitative Data Analysis
Co-Investigators: C. Leep, M.S., M.P.H., R. Willard, M.P.H.

In this study, we examine qualitative data pertaining to programmatic cuts in local health departments (LHDs) resulting from adverse economic conditions. These data include detailed information about the nature of public health services eliminated, anticipated impacts on the health of communities, and drivers of decision-making about which services, programs or activities to reduce as a result of budget loss. This study involves analysis of qualitative data from two waves of Economic Surveillance Surveys (ESS) of LHDs – the first conducted in August of 2009 and the second to be conducted in January of 2010. Both of the ESSs are based on nationally representative stratified random samples. We have used QSR NVivo to organize, code, and synthesize qualitative data. Our preliminary analyses of the 2009 ESS show that budget reductions lead to reduction or elimination of a wide variety of public health services and activities, including essential public health functions that are not provided by other agencies. Consequently, LHDs reported that they expected serious community health impacts, including spread of infectious disease, negative MCH outcomes, unintended pregnancies, undetected chronic disease and cancers, and spread of food-borne illness.  The results from the 2010 survey will provide additional information about decision drivers in service reduction due to budget loss by LHDs.  These findings add to the evidence-base and provide valuable insights to local health department leaders and local government officials in a general economic downturn for understanding expected relative impact to their agency. The LHD leaders will also benefit from qualitative details concerning service-reduction decisions and factors to consider when making such decisions. The findings may allow state and federal public health leaders to make better decisions about resource allocation, particularly at times when budgets are declining.