Local Fiscal Allocation for Public Health Departments

Investigating the Role of Local Board of Health Governance on Local Health Department Policymaking Behavior

OBJECTIVES

This study sought to identify groupings of policymaking behavior among local governmental health departments (LHDs) across the country and assess whether such groupings were associated with the governance activity of their board of health (BOH).

DESIGN

We conducted latent class analysis (LCA) to identify possible classes of policymaking behavior among LHDs. Once classes were identified, we used multinomial logistic regression (MLN) to estimate the association between an LHD's policymaking behavior and the governance activity of their BOH.

SETTING

2019 wave of the National Association of City and County Health Officials (NACCHO) Profile Survey.

PARTICIPANTS

All LHDs with BOHs in the 2019 NACCHO Profile Survey (n = 1003).

OUTCOME MEASURES

Within our MLN, our primary outcome of interest was the association between an LHD's policymaking class (the main dependent variable) and the governance activity of its BOH (the main independent variable).

RESULTS

Based on our LCA, we determined our sample to be composed of what we characterized as "Limited Policy-Involvement," "Average Policy Involvement," and "Expanded Policy Involvement" LHDs. Those in the Expanded Class were more likely to be involved across all policy areas compared to the Limited and Average class, especially among social determinants of health (SDOH)-related areas. Our MLN estimated that having a BOH active in legal authority was associated with an 86% increased chance that an LHD would be in the "Average Class" compared to the "Limited Class" and having a BOH active in partnership engagement was associated with an 86% more likely chance that an LHD is in the "Expanded Class" compared to the "Average Class."

CONCLUSION

Using nationally representative data on LHD activity, we found distinct groups of policymaking behavior, including a quarter of LHDs that are highly active in traditional and SDOH-related policy areas. We also found that groupings of policymaking behavior, as indicated by class designation, are strongly associated with the BOH's governance activity.

Contemporary Public Health Finance: Varied Definitions, Patterns, and Implications

The financing of public health systems and services relies on a complex and fragmented web of partners and funding priorities. Both underfunding and "dys-funding" contribute to preventable mortality, increases in disease frequency and severity, and hindered social and economic growth. These issues were both illuminated and magnified by the COVID-19 pandemic and associated responses. Further complicating issues is the difficulty in constructing adequate estimates of current public health resources and necessary resources. Each of these challenges inhibits the delivery of necessary services, leads to inequitable access and resourcing, contributes to resource volatility, and presents other deleterious outcomes. However, actions may be taken to defragment complex funding paradigms toward more flexible spending, to modernize and standardize data systems, and to assure equitable and sustainable public health investments.

Regarding Investment in a Healthier Future: Impact of the 2012 Institute of Medicine Finance Report

CONTEXT

Governments at all levels work to ensure a healthy public, yet financing, organization, and delivery of public health services differ across the United States. A 2012 Institute of Medicine Finance report provided a series of recommendations to ensure a high-performing and adequately funded public health infrastructure.

OBJECTIVES

This review examines the influence of the Finance report's 10 recommendations on public health policy and practice.

DESIGN

This review utilized peer-reviewed and gray literature published since 2012.

ELIGIBILITY CRITERIA

Documents that address at least one of the Finance report's 10 recommendations and contain information on either official actions taken in response to the Finance report or evidence of the report's influence on the practice community.

RESULTS

Of 2394 unique documents found, a total of 56 documents met the eligibility criteria. Review of these 56 documents indicated that the most substantial activity related to the recommendations was focused on the "minimum package of public health services" concept and establishment of a uniform chart of accounts.

DISCUSSION

Progress has been mixed on the Finance report recommendations. Improved tracking and auditing of public health activity appears to be advancing, yet financial benchmarks remain unmet. Challenges remain in determining actual investment in public health and equitable resource allocation approaches. State and local health department use of cost estimation methodology and a uniform chart of accounts tool has contributed to an increase in understanding and improvement in public health spending.

CONCLUSIONS

The Finance report has served as a strong impetus for advocating for an increased investment in governmental public health. Efforts are bolstered by informed public health practitioners and stakeholders but often stymied by policy makers who must balance complex competing issues and priorities. Although many successes have occurred, further work is needed toward improving investment in the nation's public health.

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.

Cost Analysis of 3 Concurrent Public Health Response Events: Financial Impact of Measles Outbreak, Super Bowl Surveillance, and Ebola Surveillance in Maricopa County

OBJECTIVE

To generate estimates of the direct costs of mounting simultaneous emergency preparedness and response activities to respond to 3 major public health events.

DESIGN

A cost analysis was performed from the perspective of the public health department using real-time activity diaries and retrospective time and activity self-reporting, wage and fringe benefit data, and financial records to track costs.

SETTING

Maricopa County Department of Public Health (MCDPH) in Arizona. The nation's third largest local public health jurisdiction, MCDPH is the only local health agency serving Maricopa's more than 4 000 000 residents. Responses analyzed included activities related to a measles outbreak with 2 confirmed cases, enhanced surveillance activities surrounding Super Bowl XLIX, and ongoing Ebola monitoring, all between January 22, 2015, and March 4, 2015.

PARTICIPANTS

Time data were sought from all MCDPH staff who participated in activities related to any of the 3 relevant responses. In addition, time data were sought from partners at the state health department and a community hospital involved in response activities. Time estimates were received from 128 individuals (response rate 88%).

MAIN OUTCOME MEASURE

Time and cost to MCDPH for each response and overall.

RESULTS

Total MCDPH costs for measles-, Super Bowl-, and Ebola-related activities from January 22, 2015, through March 4, 2015, were $224 484 (>5800 hours). The majority was for personnel ($203 743) and the costliest response was measles ($122 626 in personnel costs). In addition, partners reported working more than 700 hours for these 3 responses during this period.

CONCLUSIONS

Funding for public health departments remains limited, yet public health responses can be cost- and time-intensive. To effectively plan for future public health responses, it may be necessary to share experiences and financial lessons learned from similar public health responses. External partnerships represent a key contribution for responses such as those examined. It can be expensive for local public health departments to mount effective responses, especially when multiple responses occur simultaneously.

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.

Local health and social services expenditures: An empirical typology of local government spending

The conceptual importance of social services to health outcomes is well known and recent empirical evidence has linked social services spending to better population health outcomes. Yet little research has been devoted to what social services spending actually entails as it relates to population health and whether broadly similar spending patterns may exist across communities. The purpose of this study was to identify empirical patterns in spending, and explore health status and outcome correlates with social services spending. Spending data come from the 2012 U.S. Census Bureau's Census of Governments, which includes spending data for 14 social services within 3129 U.S. counties. Additional 2012 demographic, socioeconomic, and population health data were obtained and analyzed at the county-level in 2017. Hierarchical cluster analysis revealed 5 clusters of counties according to local government spending. One group had significantly lower income, social services spending, health indicators, and health outcomes than other counties. Two other groups had relatively high income, high social services spending, and strong health outcomes and indicators. Yet these latter two groups invested differently, with one spreading spending across a larger number of social services and the other concentrating spending in a smaller number of services such as education. Determining the extent to which spending approaches contribute to population health may offer communities guidance for maximizing population health. While it cannot establish causality, this study adds to the literature regarding the ways in which communities invest in both health care and social services to prevent disease and promote population health.

Associations Between County Wealth, Health and Social Services Spending, and Health Outcomes

INTRODUCTION

Each year, the County Health Rankings rate the health outcomes of each county in the U.S. A common refrain is that poor counties perform worse than wealthier ones. This article examines that assumption and specifically analyzes characteristics of counties that have performed better in terms of health outcomes than their wealth alone would suggest.

METHODS

Data from the 2013 County Health Rankings were used, as were 2012 financial and demographic information collected by the U.S. Census Bureau. A logistic model was constructed to examine the odds of a county "overperforming" in the rankings relative to community wealth. Analyses were performed in 2016.

RESULTS

Communities that were wealthier performed better on the rankings. However, more than 800 of 3,141 counties overperformed by ranking in a better health outcomes quartile than their county's wealth alone would suggest. Regression analyses found that for each additional percentage point of total public spending that was allocated toward community health care and public health, the odds of being an overperformer increased by 3.7%.

CONCLUSIONS

Community wealth correlates with health, but not always. Population health outcomes in hundreds of counties overperform what would be expected given community wealth alone. These counties tend to invest more in community health care and public health spending and other social services. Although the level of a community's wealth is outside the control of practitioners, shifting the proportion of spending to certain social services may positively impact population health.

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.