Years of budget cuts to public health led to the elimination of more than 55,000 positions within local health departments from 2008 through 2017, according to a report released Wednesday.
The Trust for America's Health estimates public health efforts are about $4.5 billion underfunded. That's led state and local health departments woefully unprepared to address public health emergencies such as infectious disease outbreaks, extreme weather events, and the opioid crisis.
"One could argue that there has always been underfunding but it is more meaningful at a period of time when cuts haven't been restored and risks have increased," said John Auerbach, president and CEO of Trust for America's Health.
Public health funding represented 2.5% of the roughly 3.5 trillion spent on healthcare in 2017, which totaled and average of $274 per person. In fiscal year 2018, state spending on public health increased by 2% to a total of $11.8 billion. Seventeen states and the District of Columbia cut their budgets that year, with some, including Alaska, Maine and Texas, decreasing their funding by more than 10% over the prior year.
Among local health departments, the report found one-fifth reported decreases in their fiscal 2017 budgets.
About a quarter of health departments serving populations of less than 50,000 reported budget cuts in both 2016 and 2017.
Both state and local health departments receive the majority of their funding from grants provided by the Prevention and Public Health Fund established under the Affordable Care Act. In fiscal 2018, the fund allocated more than $586 million of its $800 million budget to states and municipalities.
The PPHF has been consistently used to fund efforts not related to public health.
In 2012, President Barack Obama signed a bill that cut the fund by more than $6 billion over nine years to pay for cuts to Medicare physician payments. A year later, the fund lost $450 million to set up the federal health insurance marketplace.
The massive tax cut passed in 2017 cut another $750 million from the fund to cover the costs of the Children's Health Insurance Program, while the budget bill passed in 2018 cut $1.35 billion from the PPHF over 10 years.
"(The fund) has been used to backfill cuts in well-established programs or it's been decreased to fund other kinds of activities," Auerbach said. "An important way of improving the financial status of the public health system would be to restore the fund to its original allocation ($15 billion over 10 years) and not have it redirected to other sources."
Auerbach wished public health efforts could receive more established funding to handle emerging threats without having to wait for Congress to approve resources. For example, experts had to request emergency funding to address the Ebola outbreak in 2014, the Zika virus in 2016, and more recently, the opioid epidemic.
"That kind of funding impedes the ability of public health to actually prevent risk or to respond in a timely manner," Auerbach said. "If the funding comes in the midst of an emergency you're quickly doing catch-up."
In addition to restoring the PPHF's funding, the report recommended increasing CDC funding by 22% by fiscal 2022 over what was funded in 2018.
The Trust for America's Health report recommended payers and providers help public health efforts by conducting patient screenings for issues such as food insecurity, housing instability and other social determinants of health.
Establishing partnerships with providers and payers was just part of what Michael Fraser, executive director for the Association of State and Territorial Health Officials, saw as public health's evolving role as both a provider of crucial health surveillance data and a connector.
"Public health has demonstrated a lot of leadership to convene both clinical partners as well as different sectors to have these conversations about social determinants and to really push this health-in-all-policies approach," Fraser said.