Local health departments and the 2008 recession: characteristics of resiliency

Not Only How Much But How: The Importance Of Diversifying Funding Streams In A Reimagined Public Health System

Revenue diversification may be a synergistic strategy for transforming public health, yet few national or trend data are available. This study quantified and identified patterns in revenue diversification in public health before and during the COVID-19 pandemic. We used National Association of County and City Health Officials' National Profile of Local Health Departments study data for 2013, 2016, 2019, and 2022 to calculate a yearly diversification index for local health departments. Respondents' revenue portfolios changed fairly little between 2016 and 2022. Compared with less-diversified local health departments, well-diversified departments reported a balanced portfolio with local, state, federal, and clinical sources of revenue and higher per capita revenues. Less-diversified local health departments relied heavily on local sources and saw lower revenues. The COVID-19 period exacerbated these differences, with less-diversified departments seeing little revenue growth from 2019 to 2022. Revenue portfolios are an underexamined aspect of the public health system, and this study suggests that some organizations may be under financial strain by not having diverse revenue portfolios. Practitioners have ways of enhancing diversification, and policy attention is needed to incentivize and support revenue diversification to enhance the financial resilience and sustainability of local health departments.

Local Health Department Engagement in Access to Mental Health Services and Mental Health Policy or Advocacy Activities

CONTEXT

Mental health is a public health concern that requires national attention at the local level. Major issues facing local health departments (LHDs) to actively engage in mental health activities include inadequate surveillance data and limited resources.

OBJECTIVE

To examine the levels of engagement in access to mental health services, as well as policy or advocacy activities, by LHDs characteristics.

DESIGN

The study design is cross-sectional based on the national survey of LHDs. We analyzed the survey data from the National Association of County and City Health Officials' 2019 Profile study. Logistic regression was performed with 6 levels of engagement in mental health activities as the outcome measures.

RESULTS

LHDs reported that a majority had assessed the gaps in access to mental health (57.69%), followed by other activities-had implemented strategies to increase access to mental health (48.77%), implemented strategies to target underserved populations (40.66%), evaluated strategies to target underserved populations (38.84%), engaged in policy/advocacy to address mental health (32.27%), and finally addressed gaps through provision of mental health (22.31%). LHDs' governance structure was strongly associated with engagement in all 6 mental health activities. LHDs that had performed improvement processes, had behavioral health staff, and had cross-jurisdictional sharing were more likely to be engaged in all 6 of the mental health activities. LHDs were also more likely to be engaged in 5 of the 6 mental health activities if they had some relationships with faith communities and in 4 of the 6 mental health activities if they had some relationships with community health centers.

CONCLUSIONS

Levels of engagement in mental health policy or advocacy activities among LHDs were low and varied by LHD characteristics. Intervention strategies may include encouraging LHDs to actively engage in mental health activities, participating in Public Health Accreditation Board accreditation program, and incentivizing mental health workforce retention.

Dance of Dollars: State Funding Effects on Local Health Department Expenditures

OBJECTIVE

We examined changes in total local health department (LHD) expenditures in the state of Washington following introduction of a new state funding program to support core public health services and infrastructure.

METHODS

We used a pre/posttest design regression model to evaluate changes in LHD expenditures 1, 2, and 6 years into the new state program. To address potential endogeneity in the model, we repeated all 3 analyses using 2-stage least squares regression.

RESULTS

In the base case, overall spending among LHDs significantly increased with receipt of the new state funds in the first years of the program (2008 and 2009). However, those increases were not sustained over the longer term (2013). In subpopulation analyses, total LHD spending increased more among larger LHDs.

CONCLUSIONS

Between 2006 and 2013, new state investments in core public health functions increased Washington State LHD expenditures in the short term, but those increases did not persist over time. For public health financial modernization efforts to translate into public health infrastructure modernization successes, the way new investments are structured may be as important as the amount of funding added.

Local Health Department Revenue Diversification and Revenue Volatility: Can One Be Used to Manage the Other?

OBJECTIVE

Revenue volatility-particularly in the form of sudden and significant reductions in funding-has been shown to negatively affect local health departments (LHDs) by impacting the amount and type of services delivered. This study examined the potential effectiveness of revenue diversification as a means of managing LHD financial risk. More specifically, we examine the relationship between revenue diversification and revenue volatility among LHDs in Washington State.

DESIGN AND SETTING

We applied fixed-effects linear regression models with robust standard errors to revenue data reported during 1998-2014 by all LHDs operating in Washington State. We also assessed the robusticity of our results to alternative specifications for revenue diversification and volatility.

MAIN OUTCOME MEASURES

LHD revenue and revenue volatility.

RESULTS

Between 1998 and 2014, LHDs in Washington State were exposed to considerable upside and downside fiscal risks. While average revenue volatility was close to 0 (0.2%), observed values ranged from -35% to 63%. LHD revenues were already highly diversified: as measured using a reversed Herfindahl-Hirschman Index, diversification values ranged between 0.56 and 1.00. There is little evidence to suggest the existence of a statistically significant relationship between revenue diversification and volatility.

CONCLUSIONS

Revenue volatility presents LHDs with important short- and long-term operational challenges. Our models suggest that revenue diversification did not reduce revenue volatility among Washington State LHDs in 1998-2014. Further research will need to examine whether revenue diversification reduces LHD financial risk in other settings.

The Local Health Department Mandate and Capacity for Community Engagement in Emergency Preparedness: A National View Over Time

CONTEXT

Local health departments (LHDs) perform the highly valued, yet time- and staff-intensive work of community engagement in public health emergency preparedness (CE-PHEP) when the Great Recession has had lingering effects on their organizational capacity.

OBJECTIVE

Track the extent to which LHDs still embrace collaborative, whole community approaches to PHEP in a historically low resource environment.

DESIGN

National survey in 2015 of LHDs using a self-administered online questionnaire regarding LHD practices and resources for CE-PHEP first fielded in 2012 ("The Community Engagement for Public Health Emergency Preparedness Survey"). Differences in 2015 survey responses were reviewed, and comparisons made between 2012 and 2015 responses.

SETTING

Randomized sample of 811 LHDs drawn from 2565 LHDs that were invited to participate in the 2010 National Profile of LHDs and participated in the 2012 CE-PHEP survey. Sample selection was stratified by geographic location and size of population served.

PARTICIPANTS

Emergency preparedness coordinators reporting on the LHDs they serve.

MAIN OUTCOME MEASURE

Community engagement in public health emergency preparedness intensity as measured by a scoring system that valued specific practices on the basis of the community capacity and public participation they represented.

RESULTS

Survey response was 30%; 243 LHDs participated. The CE-PHEP activities and intensity scores remained unchanged from 2012 to 2015. Local health departments that reported having an explicit CE-PHEP policy and experienced CE-PHEP staff member--2 of the top 3 predictors of CE-PHEP intensity--have dropped between 2012 and 2015. The numbers of LHDs with a CE-PHEP budget, also an important predictor of intensity, have not increased in a statistically significant way during that same period.

CONCLUSIONS

Local health departments appear to be in a CE-PHEP holding pattern, presumably pushed forward by the doctrinal focus on partner-centered preparedness but held back by capacity issues, in particular, limited staff and partner support. Local health departments operating in low-resource environments are encouraged to formalize their CE-PHEP policy to advance performance in this arena.

Data, Staff, and Money: Leadership Reflections on the Future of Public Health Informatics

CONTEXT

Health informatics can play a critical role in supporting local health departments' (LHDs') delivery of certain essential public health services and improving evidence base for decision support. However, LHDs' informatics capacities are below an optimum level. Efforts to build such capacities face ongoing challenges. Moreover, little is known about LHD leaders' desires for the future of public health informatics.

OBJECTIVES

Conduct a qualitative analysis of LHDs' future informatics plans, perceived barriers to accomplishing those plans, and potential impact of future advances in public health informatics on the work of the public health enterprise.

METHODS

This research presents findings from 49 in-depth key informant interviews with public health leaders and informatics professionals from LHDs, representing insights from across the United States. Interviewees were selected on the basis of the size of the population their LHD serves, as well as level of informatics capacity. Interviews were transcribed, verified, and double coded.

RESULTS

Major barriers to doing more with informatics included staff capacity and training, financial constraints, dependency on state health agency, and small LHD size/lack of regionalization. When asked about the role of leadership in expanding informatics, interviewees said that leaders could make it a priority through (1) learning more about informatics and (2) creating appropriate budgets for integrated information systems. Local health department leaders said that they desired data that were timely and geographically specific. In addition, LHD leaders said that they desired greater access to clinical data, especially around chronic disease indicators.

CONCLUSIONS

Local health department leadership desires to have timely or even real-time data. Local health departments have a great potential to benefit from informatics, particularly electronic health records in advancing their administrative practices and service delivery, but financial and human capital represents the largest barrier. Interoperability of public health systems is highly desirable but hardly achievable in the presence of such barriers.

How Much Do We Spend? Creating Historical Estimates of Public Health Expenditures in the United States at the Federal, State, and Local Levels

The United States has a complex governmental public health system. Agencies at the federal, state, and local levels all contribute to the protection and promotion of the population's health. Whether the modern public health system is well situated to deliver essential public health services, however, is an open question. In some part, its readiness relates to how agencies are funded and to what ends. A mix of Federalism, home rule, and happenstance has contributed to a siloed funding system in the United States, whereby health agencies are given particular dollars for particular tasks. Little discretionary funding remains. Furthermore, tracking how much is spent, by whom, and on what is notoriously challenging. This review both outlines the challenges associated with estimating public health spending and explains the known sources of funding that are used to estimate and demonstrate the value of public health spending.

Enhancing the Science of Discovery in Public Health Systems and Services Research Through Participatory Research Methods

The objective was to combine cost analysis and participatory research to identify actionable cost-saving opportunities in public health services for sexually transmitted infections (STI). This study used a mixed-methods approach of analyzing Florida public health data, combined with participatory research approaches to data collection including quantitative web-based surveys, qualitative in-depth interviews, and group discussions. Florida surveillance and administrative data on STIs and county health department (CHD) costs of services for 2012 were analyzed in addition to primary data collected from all Florida CHDs during 2014 and 2015. Variations in STI service delivery practices were the primary variables of concern. Variations in practices, rather than demographic factors such as size of county or STI rates, were associated with variations in cost. Five identified variations in practices were rated for cost savings, no or minimal adverse health impact, and ease of implementation. Following discussion of the ratings by CHDs, texting STI test results was ranked highest for quality improvement implementation initiatives. This study provides a compelling example of how in-depth qualitative and quantitative follow-up research focused on discovery and development with the practice community provides critical insights for interpreting administrative data and drawing accurate reality-based conclusions. The research design was intended to be a highly adaptive research approach that adjusts to the political and technical circumstances of delivering public health services. The extensive stakeholder engagement throughout all phases the study enables this research to address and overcome potential barriers and challenges to actionable findings.

Creating a Taxonomy of Local Boards of Health Based on Local Health Departments' Perspectives

OBJECTIVES

To develop a local board of health (LBoH) classification scheme and empirical definitions to provide a coherent framework for describing variation in the LBoHs.

METHODS

This study is based on data from the 2015 Local Board of Health Survey, conducted among a nationally representative sample of local health department administrators, with 394 responses. The classification development consisted of the following steps: (1) theoretically guided initial domain development, (2) mapping of the survey variables to the proposed domains, (3) data reduction using principal component analysis and group consensus, and (4) scale development and testing for internal consistency.

RESULTS

The final classification scheme included 60 items across 6 governance function domains and an additional domain-LBoH characteristics and strengths, such as meeting frequency, composition, and diversity of information sources. Application of this classification strongly supports the premise that LBoHs differ in their performance of governance functions and in other characteristics.

CONCLUSIONS

The LBoH taxonomy provides an empirically tested standardized tool for classifying LBoHs from the viewpoint of local health department administrators. Future studies can use this taxonomy to better characterize the impact of LBoHs.

Assuring a strong foundation for our nation's public health systems

BACKGROUND

A strong public health infrastructure is necessary to assure that every community is capable of carrying out core public health functions (assessment of population health, assurance of accessible and equitable health resources, and development of policies to address population health) to create healthy conditions. Yet, due to budget cuts and inconsistent approaches to base funding, communities are losing critical prevention and health promotion services and staff that deliver them.

PURPOSE

This article describes key components of and current threats to our public health infrastructure and suggests actions necessary to strengthen public health systems and improve population health.

DISCUSSION

National nursing and public health organizations have a duty to advocate for policies supporting strong prevention systems, which are crucial for well-functioning health care systems and are fundamental goals of the nursing profession.

CONCLUSION

We propose strengthening alliances between nursing organizations and public health systems to assure that promises of a reformed health system are achieved.

Local Fiscal Allocation for Public Health Departments

INTRODUCTION

We examined the percentage of local government taxes ("fiscal allocation") dedicated to local health departments on a national level, as well as correlates of local investment in public health.

METHODS

Using the most recent data available--the 2008 National Association of City and County Health Officials Profile survey and the 2007 U.S. Census Bureau Census of Local Governments-generalized linear regression models examined associations between fiscal allocation and local health department setting, governance, finance, and service provision. Models were stratified by the extent of long-term debt for the jurisdiction. Analyses were performed in 2014.

RESULTS

Average fiscal allocation for public health was 3.31% of total local taxes. In multivariate regressions, per capita expenditures, having a local board of health and public health service provision were associated with higher fiscal allocation. Stratified models showed that local board of health and local health department taxing authority were associated with fiscal allocation in low and high long-term debt areas, respectively.

CONCLUSIONS

The proportion of all local taxes allocated to local public health is related to local health department expenditures, service provision, and governance. These relationships depend upon the extent of long-term debt in the jurisdiction.

Trends and characteristics of the state and local public health workforce, 2010-2013

OBJECTIVES

We assessed state and local public health workforce characteristics by occupational category from 2010 to 2013. We also examined health department characteristics to determine whether workforce size and composition varied across these domains.

METHODS

We analyzed Association of State and Territorial Health Officials (2010, 2012) and National Association of County and City Health Officials (2010, 2013) profile study data, including 47 state health departments and 2005 and 1953 local health departments (LHDs) in 2010 and 2013, respectively. We determined number of workers and percentage of change by occupation, population size, geographic region, and governance structure.

RESULTS

The LHD workforce remained stable between 2010 and 2013. In states, the workforce decreased by 4%, with notable decreases in public information (-33%) and public health informatics (-29%); state health departments in small (-9%), New England (-13%), and centralized (-7%) states reported the largest decrease in number of workers.

CONCLUSIONS

Study findings provide evidence of a shifting public health workforce profile, primarily at the state level. Future research should seek to explain changing workforce patterns and determine whether they are planned or forced responses to changing budgets and service priorities.

Changes in public health workforce composition: proportion of part-time workforce and its correlates, 2008-2013

BACKGROUND

State and local public health department infrastructure in the U.S. was impacted by the 2008 economic recession. The nature and impact of these staffing changes have not been well characterized, especially for the part-time public health workforce.

PURPOSE

To estimate the number of part-time workers in state and local health departments (LHDs) and examine the correlates of change in the part-time LHD workforce between 2008 and 2013.

METHODS

We used workforce data from the 2008 and 2013 National Association of County and City Health Officials (n=1,543) and Association of State and Territorial Health Officials (n=24) profiles. We employed a Monte Carlo simulation to estimate the possible and plausible proportion of the workforce that was part-time, over various assumptions. Next, we employed a multinomial regression assessing correlates of the change in staffing composition among LHDs, including jurisdiction and organizational characteristics, as well measures of community involvement.

RESULTS

Nationally representative estimates suggest that the local public health workforce decreased from 191,000 to 168,000 between 2008 and 2013. During that period, the part-time workforce decreased from 25% to 20% of those totals. At the state level, part-time workers accounted for less than 10% of the total workforce among responding states in 2013. Smaller and multi-county jurisdictions employed relatively more part-time workers.

CONCLUSIONS

This is the first study to create national estimates regarding the size of the part-time public health workforce and estimate those changes over time. A relatively small proportion of the public health workforce is part-time and may be decreasing.