Assessing The Value Of 40 Years Of Local Public Expenditures On Health

Seeking outcomes under tight budgets: A case for health impact bonds in Post-COVID times

With global public debt at record levels, governments are facing unprecedented challenges in providing essential health services. This exploratory study aims to assess the relevance of Health Impact Bonds (HIBs) as a means of financing preventative health services during times of fiscal constraint and in the aftermath of the COVID pandemic. The study draws on a review of the literature on HIBs, along with a case study analysis of HIBs implemented in the UK. The findings of the study indicate that, although HIBs offer promise as an innovative funding tool for preventative health services in tight fiscal situations, certain challenges are limiting their broader adoption.

Associations between county-level public health expenditures and community health planning activities with COVID-19 incidence and mortality

The COVID-19 pandemic has revealed consequences of past defunding of the U.S. public health system, but the extent to which public health infrastructure is associated with COVID-19 burden is unknown. We aimed to determine whether previous county-level public health expenditures and community health planning activities are associated with COVID-19 cases and deaths. We examined 3050 of 3143 U.S. counties and county equivalents from March 1, 2020 to February 28, 2022. Multivariable-adjusted linear regression and generalized additive models were used to estimate associations between county-level public health expenditures and completion of community health planning activities by a county health department with outcomes of county-level COVID-19 cases and deaths per 100,000 population. After adjusting for county-level covariates, counties in the highest tertile of public health expenditures per capita had on average 542 fewer COVID-19 cases per 100,000 population (95% CI, -1004 to -81) and 21 fewer deaths per 100,000 population (95% CI, -32 to -10) than counties in the lowest tertile. For analyses of community health planning activities, adjusted estimates of association remained negative for COVID-19 deaths, but confidence intervals included negative and positive values. In conclusion, higher levels of local public health expenditures and community health planning activities were associated with fewer county-level COVID-19 deaths, and to a lesser extent, cases. Future public health funding should be aligned with evidence for the value of county health departments programs and explore further which types of spending are most cost effective.

What drives variations in public health and social services expenditures? the association between political fragmentation and local expenditure patterns

The US spends two times more than the OECD average in health expenditure but has a much smaller portion of public health spending to total health expenditure than other OECD countries. While it has been suggested that public health and social services spending is crucial to promoting health outcomes, less is known about what drives variations in public health expenditure across regions. This study aims to examine whether political fragmentation in local governance is associated with variations in public health and social services expenditures. Using the US Census of Governments, we constructed a panel dataset of political fragmentation and local government spending patterns (1997-2012) for 792 US counties (population > 60,882, top 25%) and employed Least Squares Dummy Variable (LSDV) and Generalized Estimating Equations (GEE) models. We found that per capita public health spending tended to be smaller in areas where the degree of political fragmentation was higher (Coef:  - 0.034; p < 0.01), particularly when general-purpose governments were more fragmented (Coef:  - 0.087; p < 0.001). The proportion of public health spending also decreased when local governments were more fragmented (Coef:  - 0.012; p < 0.001). Social services expenditures and their proportions to total government expenditure fell with an increase in the degree of political fragmentation. Our findings suggest that fragmented governance settings, in which localities are more likely to face competition with others, may lead to a reduction in public spending essential for population health and that political fragmentation can also have a deterrent effect on broader categories of health-related social services spending.

Estimating the Association Between Public Health Spending and Sexually Transmitted Disease Rates in the United States: A Systematic Review

ABSTRACT

Public health spending is important for managing increases in sexually transmitted diseases (STDs) in the United States. Although previous studies suggest that a beneficial link exists between public health spending and changes in STD rates, there have been no systematic reviews synthesizing existing evidence regarding the association for STDs at the population level. The objective of this study was to synthesize evidence from studies that assessed the associations between general and STD-specific public health spending and STD rates. We conducted a systematic review using Ovid-Medline, EMBASE, CINAHL, Cochrane Library, Web of Science, and EconLit for relevant studies that examined the association between public health spending and gonorrhea, syphilis, chlamydia, and chancroid rates following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 5 articles (2 regarding general public health spending and 3 regarding STD-specific public health spending) met our inclusion criteria. There was a significant decrease in gonorrhea, syphilis, chlamydia, and chancroid rates associated with increased public health spending. We also found that STD-specific public health spending has a greater effect on STD rates compared with general public health spending. Our review provides evidence that increases in general and STD-specific public health spending are associated with a reduction of STD rates. Such research regarding estimates of the impact of STD prevention spending can help policy makers identify priority funding areas and inform health resource allocation decisions.

Life expectancy and risk of death in 6791 communities in England from 2002 to 2019: high-resolution spatiotemporal analysis of civil registration data

BACKGROUND

High-resolution data for how mortality and longevity have changed in England, UK are scarce. We aimed to estimate trends from 2002 to 2019 in life expectancy and probabilities of death at different ages for all 6791 middle-layer super output areas (MSOAs) in England.

METHODS

We performed a high-resolution spatiotemporal analysis of civil registration data from the UK Small Area Health Statistics Unit research database using de-identified data for all deaths in England from 2002 to 2019, with information on age, sex, and MSOA of residence, and population counts by age, sex, and MSOA. We used a Bayesian hierarchical model to obtain estimates of age-specific death rates by sharing information across age groups, MSOAs, and years. We used life table methods to calculate life expectancy at birth and probabilities of death in different ages by sex and MSOA.

FINDINGS

In 2002-06 and 2006-10, all but a few (0-1%) MSOAs had a life expectancy increase for female and male sexes. In 2010-14, female life expectancy decreased in 351 (5·2%) of 6791 MSOAs. By 2014-19, the number of MSOAs with declining life expectancy was 1270 (18·7%) for women and 784 (11·5%) for men. The life expectancy increase from 2002 to 2019 was smaller in MSOAs where life expectancy had been lower in 2002 (mostly northern urban MSOAs), and larger in MSOAs where life expectancy had been higher in 2002 (mostly MSOAs in and around London). As a result of these trends, the gap between the first and 99th percentiles of MSOA life expectancy for women increased from 10·7 years (95% credible interval 10·4-10·9) in 2002 to reach 14·2 years (13·9-14·5) in 2019, and for men increased from 11·5 years (11·3-11·7) in 2002 to 13·6 years (13·4-13·9) in 2019.

INTERPRETATION

In the decade before the COVID-19 pandemic, life expectancy declined in increasing numbers of communities in England. To ensure that this trend does not continue or worsen, there is a need for pro-equity economic and social policies, and greater investment in public health and health care throughout the entire country.

FUNDING

Wellcome Trust, Imperial College London, Medical Research Council, Health Data Research UK, and National Institutes of Health Research.

County health outcomes linkage to county spending on social services, building infrastructure, and law and order

Will counties that reallocate money from law enforcement to social services improve subsequent markers of population wellbeing? In this study, we measure the association between county government spending across multiple sectors and Life Expectancy at Birth (LEB) in the U.S. using data from the U.S. Census Bureau. We constructed a Structural Equation Model to determine whether social expenditure, building infrastructure, and spending on law and order were positively or negatively associated with LEB three-years after initial spending. The analysis compared data between 2002-05 and 2007-10 and was stratified for urban and rural counties. In rural counties, a one-standard-deviation increase in social spending increased subsequent LEB by 0.58 (SE 0.16) and 0.36 (SE 0.16) years in 2005 and 2010, respectively. In urban counties, a one-standard-deviation increase in building infrastructure spending increased subsequent LEB by 1.14 (SE 0.51) and 1.05 (SE 0.49) years in 2005 and 2010, respectively. In 2002, a one-standard-deviation increase in law and order spending significantly decreased subsequent life expectancy, 2.2 (SE 1.27) and 0.46 (SE 0.13) years in urban and rural counties, respectively. Similarly, investments in building infrastructure for urban counties and social services for rural counties were associated with subsequently higher life expectancy three years later after initial investments.

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Funding for public health and other social interventions is associated with subsequent improvements in life expectancy.

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Spending in the social services is more closely tied to future life expectancy at birth in rural counties.

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In urban counties spending on building infrastructure is associated with more future gains in life expectancy at birth.

Does Medicaid expansion influence county health spending? A case of New York counties

We investigated the impacts of Medicaid expansion on New York county total health spending and specifics of health spending, including health services, public health facilities and public health administration. Little research considered the financial effect of Medicaid expansion on local governments while well reported are its influences on uninsured rates and health services utilization. New York counties have contributed to health in their boundaries by providing or funding public health services, and supporting a part of the non-federal share of Medicaid expenditures and uncompensated care. Medicaid expansion can reduce the size of county expenditures for health by enrolling more previously uninsured population in the program and offering more generous federal funding for the expanded Medicaid. We offer empirical evidence that Medicaid expansion was associated with reduced county health spending.

Local government funding and life expectancy in England: a longitudinal ecological study

Background

Since 2010, large reductions in funding for local government services have been introduced in England. These reductions in funding have potentially led to reduced provision of health-promoting public services. We aimed to investigate whether areas that showed a greater decline in funding also had more adverse trends in life expectancy and premature mortality.

Methods

In this longitudinal ecological study, we linked annual data from the Ministry of Housing, Communities, and Local Government on local government revenue expenditure and financing to 147 upper-tier local authorities in England between 2013 and 2017 with data from Public Health England, on male and female life expectancy at birth, male and female life expectancy at age 65 years, and premature (younger than 75 years) all-cause mortality rate for male and female individuals. Local authorities were excluded if their populations were too small or if changes in boundaries meant consistent data were not available. Using multivariable fixed-effects panel regression models, and controlling for local socioeconomic conditions, we estimated whether changes in local funding from 2013 were associated with changes in life expectancy and premature mortality. We included a set of alternative model specifications to test the robustness of our findings.

Findings

Between 2013 and 2017, mean per-capita central funding to local governments decreased by 33% or £168 per person (range –£385 to £1). Each £100 reduction in annual per person funding was associated over the study period 2013–17 with an average decrease in life expectancy at birth of 1·3 months (95% CI 0·7–1·9) for male individuals and 1·2 months (0·7–1·7) for female individuals; for life expectancy at age 65 years, the results show a decrease of 0·8 months (0·3–1·3) for male individuals and 1·1 months (0·7–1·5) for female individuals. Funding reductions were greater in more deprived areas and these areas had the worst changes in life expectancy. We estimated that cuts in funding were associated with an increase in the gap in life expectancy between the most and least deprived quintiles by 3% for men and 4% for women. Overall reductions in funding during this period were associated with an additional 9600 deaths in people younger than 75 years in England (3800–15 400), an increase of 1·25%.

Interpretation

Our findings indicate that cuts in funding for local government might in part explain adverse trends in life expectancy. Given that more deprived areas showed greater reductions in funding, our analysis suggests that inequalities have widened. Since the pandemic, strategies to address these adverse trends in life expectancy and reduce health inequalities could prioritise reinvestment in funding for local government services, particularly within the most deprived areas of England.

Funding

National Institute for Health Research (NIHR) School for Public Health Research, NIHR Applied Research Collaboration North East and North Cumbria, NIHR Applied Research Collaboration North West Coast and Medical Research Council.

US Public Health Neglected: Flat Or Declining Spending Left States Ill Equipped To Respond To COVID-19

The COVID-19 pandemic has prompted concern about the integrity of the US public health infrastructure. Federal, state, and local governments spend $93 billion annually on public health in the US, but most of this spending is at the state level. Thus, shoring up gaps in public health preparedness and response requires an understanding of state spending. We present state spending trends in eight categories of public health activity from 2008 through 2018. We obtained data from the Census Bureau for all states except California and coded the data by public health category. Although overall national health expenditures grew by 4.3 percent in this period, state governmental public health spending saw no statistically significant growth between 2008 and 2018 except in injury prevention. Moreover, state spending levels on public health were not restored after cuts experienced during the Great Recession, leaving states ill equipped to respond to COVID-19 and other emerging health needs.

Is an ounce of prevention worth a pound of cure? A cross-sectional study of the impact of English public health grant on mortality and morbidity

OBJECTIVES

The UK government is proposing to cease cutting the local authority public health grant by reallocating part of the treatment budget to preventative activity. This study examines whether this proposal is evidenced based and, in particular, whether these resources are best reallocated to prevention, or whether this expenditure would generate more health gains if used for treatment.

METHODS

Instrumental variable regression methods are applied to English local authority data on mortality, healthcare and public health expenditure to estimate the responsiveness of mortality to variations in healthcare and public health expenditure in 2013/14. Using a well-established method, these mortality results are converted to a quality-adjusted life year (QALY) basis, and this facilitates the estimation of the cost per QALY for both National Health Service (NHS) healthcare and local public health expenditure.

RESULTS

Saving lives and improving the quality of life requires resources. Our estimates suggest that each additional QALY costs about £3800 from the local public health budget, and that each additional QALY from the NHS budget costs about £13 500. These estimates can be used to calculate the number of QALYs generated by a budget boost. If we err on the side of caution and use the most conservative estimates that we have, then an additional £1 billion spent on public health will generate 206 398 QALYs (95% CI 36 591 to 3 76 205 QALYs), and an additional £1 billion spent on healthcare will generate 67 060 QALYs (95% CI 21 487 to 112 633 QALYs).

CONCLUSIONS

Additional public health expenditure is very productive of health and is more productive than additional NHS expenditure. However, both types of expenditure are more productive of health than the norms used by National Institute for Health and Care Excellence (£20 000-£30 000 per QALY) to judge whether new therapeutic technologies are suitable for adoption by the NHS.

The Importance of Governmental and Nongovernmental Investments in Public Health and Social Services for Improving Community Health Outcomes

OBJECTIVE

To explore whether health outcomes are influenced by both governmental social services spending and hospital provision of community health services.

DESIGN

We combined hospital provision of community health services data from the American Hospital Association with local governmental spending data from the US Census Bureau. Longitudinal models regressed community health outcomes for 2012-2016 on local government spending on health, social services, and education from 5 years previously, controlling for sociodemographic and hospital marketplace characteristics, spatial autocorrelation, and state-level random effects. For counties with hospitals, models also included county-level data on hospitals' provision of community health services.

SETTING

All analyses were performed at the county level for US counties between 2012 and 2016.

PARTICIPANTS

Complete spending, hospital, and health outcomes data were available for a total of 2379 counties.

MAIN OUTCOME MEASURES

We examined relationships between governmental spending, hospital service provision, and 5 population health outcome measures: years of potential life lost prior to age 75 years per 100 000 population, percentage of population in fair or poor health, percentage of adults who are physically inactive, deaths due to injury per 100 000 population, and percentage of births that are of low birth weight.

RESULTS

Governmental investments in health, social services, and education positively impacted key health outcomes but mainly in counties with 1 or more hospitals present. Hospitals' provision of community health services also had a significant positive impact on health outcomes.

CONCLUSIONS

Hospital provision of community health services and increases in local governmental health and social services spending were both associated with improved health. Collaboration between local governments and hospitals may help ensure that public and private community health resources synergistically contribute to the public's health. Local policy makers should consider service provision by the private sector to leverage the public investments in health and social services.

Government Health and Social Services Spending Show Evidence of Single-Sector Rather Than Multi-Sector Pursuit of Population Health

Population health improvements can be achieved through work made possible by government spending on health care, public health, and social services. The extent to which spending allocations across these sectors is synergistic with or trade-off against one another is unknown. Achieving a balanced portfolio with multi-sector contributions is key to improving health outcomes. This study tested competing hypotheses regarding achievement of balanced multi-sector resources for health. County-level U.S. Census Bureau data on all local governmental spending measured each county’s average per capita local government spending for public hospitals, public health, social services, and education. American Hospital Association (AHA) Annual Survey data on hospital community health service provision were used to calculate an index of hospital community service provision aggregated to county level by year. County Health Rankings data measured each county’s health outcomes and health factors. Longitudinal mixed-effects regression models (n = 1877 counties) predicted changes in spending for each government spending category based on two sets of predictors (government spending vs community health services and needs) from current and prior year. Models account for average spending in each category and county-, state-, and time-trends. Models showed that spending increases in each of the four spending categories examined (public hospitals, public health, social services, and education) were not associated with changes in spending across other categories in current or prior years. For all categories, an increase from baseline spending levels in Year 1 was always significantly associated with an increase from baseline spending level in that same category in Year 2 (ie, spending stayed above baseline in Year 2). Multi-sector initiatives to health outcomes require funding across sectors, yet there was little evidence to suggest that communities that invest in public hospitals, public health, or other social services see commensurate increases in other areas. Underlying funding decisions may reflect strategic decisions within a community to scale up single sectors, constrained resources for multi-sector scale up, or a host of additional factors not measured here.

Impacts of Federal Prevention Funding on Reported Gonorrhea and Chlamydia Rates

INTRODUCTION

The Centers for Disease Control and Prevention allocates funds annually to jurisdictions nationwide for sexually transmitted infection prevention activities. The objective of this study was to assess the effectiveness of federal sexually transmitted infection prevention funding for reducing rates of reported sexually transmitted infections.

METHODS

In 2017-2018, finite distributed lag regression models were estimated to assess the impact of sexually transmitted infection prevention funding (in 2016 dollars per capita) on reported chlamydia rates from 2000 to 2016 and reported gonorrhea rates from 1981 to 2016. Including lagged funding measures allowed for assessing the impact of funding over time. Controls for state-level socioeconomic factors, such as poverty rates, were included.

RESULTS

Results from the main model indicate that a 1% increase in annual funding would cumulatively decrease chlamydia and gonorrhea rates by 0.17% (p<0.10) and 0.33% (p<0.05), respectively. Results were similar when stratified by sex, with significant decreases in rates of reported chlamydia and gonorrhea in males of 0.33% and 0.34% (both p<0.05) respectively, and in rates of reported gonorrhea in females of 0.32% (p<0.05). The results were generally consistent across alternative model specifications and other robustness tests.

CONCLUSIONS

The significant inverse associations between federal sexually transmitted infection prevention funding and rates of reported chlamydia and gonorrhea suggest that federally funded sexually transmitted infection prevention activities have a discernable effect on reducing the burden of sexually transmitted infections. The reported sexually transmitted infection rate in a given year depends more on prevention funding in previous years than on prevention funding in the current year, demonstrating the importance of accounting for lagged funding effects.

The Importance of Health and Social Services Spending to Health Outcomes in Texas, 2010-2016

OBJECTIVES

Public health and social services spending have been shown to improve health outcomes at the county level, although there are significant state and regional variations in such spending. Texas offers an important opportunity for examining nuances in the patterns of association between local government health and social services spending and population health outcomes. The primary objectives of this study were to describe local investments in education, health, and social services at the county-area level for all of Texas from 2002 through 2012 and to examine how changes in local investment over time were associated with changes in health outcomes.

METHODS

We used two large secondary data sources for this study. First, US Census Bureau data were used to measure annual spending by all local governments on public hospitals, community health care and public health, and >1 dozen social services. Second, County Health Rankings & Roadmaps data measured county health outcomes. We performed regression models to examine the association between increases in local government spending and a county's health outcomes ranking 4 years later. Multilevel mixed-effects linear regression models accounted for mean spending in each category, county health factors ranking, and county and state random effects.

RESULTS

Local governments in Texas spent an average of $4717 per capita across all health and social services. Although spending was relatively consistent across 2002-2012, there was notable variation in spending across counties and services. Regression models found that changes in four spending categories were associated with significant improvements in health outcomes: fire and ambulance, community health care and public health, housing and community development, and libraries. For each, an additional one-time investment of $15 per capita was associated with a 1-spot improvement in statewide county health rankings within 4 years.

CONCLUSIONS

Existing evidence regarding the association between social services spending and health outcomes may not yield sufficiently granular data for policy makers within a single state. Investments in certain social services in Texas were associated with improvements in health outcomes, as measured by improvements in the County Health Rankings, in the years subsequent to spending increases. Similar analyses in other states and regions may yield actionable avenues for policy makers to improve population health.

Community Health and Employee Work Performance in the American Manufacturing Environment

Although better community health has long been assumed to be good for local businesses, evidence demonstrating the relationship between community health and employee performance is quite limited. Drawing on human resources data on 6103 employees from four large US manufacturing plants, we found that employees living in counties with poor community health outcomes had considerably higher rates of absenteeism and tardiness (ABT). For example, in one company, employees living in communities with high rates of children on free or reduced lunch had higher rates of ABT compared to other employees [adjusted odds ratio (OR) 2.76, 95% confidence interval (CI) 2.52-3.04], and employees living in communities with high rates of drug overdose deaths had higher rates of ABT (OR 1.51, 95% CI 1.29-1.77). In one plant, the annual value of lost wages due to ABT was over $1.3 million per year. Employees reported that poor community health (e.g., poverty, caregiving burdens, family dysfunction, drug use) resulted in "mental stress" leading to distraction, poor job performance, and more rarely, lapses in safety. These findings bolster the case for greater private sector investment in community health.