Expenditures for public health: Assessing historical and prospective trends

American Journal of Public Health

Volumn 99, Issue 10, 2009, Pages 1780-1791

  Kinner, Kyle ^a   Pellegrini, Cindy ^b,c  

^a Policy and Advocacy Unit   (United States)

^b AMERICAN ACADEMY OF PEDIATRICS   (United States)

^c NONE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; BUDGET; FUNDING; GOVERNMENT; HEALTH CARE; HEALTH CARE COST; HEALTH CARE SYSTEM; HEALTH SERVICE; MEDICAL RESEARCH; POLICY; PROPHYLAXIS; PUBLIC HEALTH SERVICE;

HEALTH EXPENDITURES; HEALTH SERVICES RESEARCH; HISTORY, 20TH CENTURY; HISTORY, 21ST CENTURY; HUMANS; LOCAL GOVERNMENT; PREVENTIVE HEALTH SERVICES; PUBLIC HEALTH; PUBLIC POLICY; STATE GOVERNMENT; UNITED STATES;

EID: 70349280609     PISSN: 00900036     EISSN: 15410048     Source Type: Journal    
DOI: 10.2105/AJPH.2008.142422     Document Type: Article

References (140)

1. See, for example, National Governors Association (NGA), Policy Position: HHS-04. Public Health Services Policy (Washington, DC: NGA, 2006);
2. George W. Bush, "Avian and Pandemic Influenza" (November 1, 2005, transmittal letter designating administration proposals for $7.1 billion in funding for influenza preparedness-related purposes), http://www.whitehouse.gov/omb/budget/amendments/supplemental-11-01-05.pdf (accessed April 6, 2008).
3. Amanda Navarro et al, "Charting the Future of Community Health Promotion: Recommendations from the National Expert Panel on Community Health Promotion," Preventing Chronic Disease 4, no.3 (2007): 1-7;
4. House Committee on Government Reform, A Review of This Year's Flu Season: Does Our Public Health System Need a Shot in the Arm?, 108th Cong., 2nd sess., February 12, 2004 (serial no. 108-143), 109-112, testimony of Karen Miller on behalf of the National Association of Counties.
5. Institute of Medicine (IOM), The Future of Public Health (Washington, DC: National Academies Press, 1988);
6. IOM, Emerging Infections: Microbial Threats to Health (Washington, DC: National Academies Press, 1992);
7. IOM, Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century (Washington, DC: National Academies Press, 2003);
8. IOM, Research Priorities in Emergency Preparedness and Response for Public Health Systems (Washington, DC: National Academies Press, 2008).
9. IOM, The Future of the Public's Health in the 21st Century (Washington, DC: National Academies Press, 2002).
10. Maria G. Sistrom and Patty J. Hale, "Outbreak Investigations: Community Participation and Role of Community and Public Health Nurses," Public Health Nursing 23 (2006): 256-63;
11. Julie Gerberding, James Hughes, and Jeffrey Koplan, "Bioterrorism Preparedness and Response: Clinicians and Public Health Agencies as Essential Partners," Journal of the American Medical Association of America (JAMA) 287 (2002): 898-900.
12. IOM, Future of Public Health, 100.
13. See also Tommy Thompson, "For Mass-Casualty Preparedness, Congress Should Fund 'ER One,"' The Hill, December 6, 2006. Asked to assess the challenges associated with disaster preparedness, the former Health and Human Services secretary stated, "More than five years after Sept. 11, 2001, no state is adequately prepared for a potential mass-casualty disaster caused by a terrorist attack, pandemic or natural disaster."
14. House Committee on Government Reform, A Review of This Year's Flu Season: Does Our Public Health System Need a Shot in the Arm?, 108th Cong., 2nd sess., February 12, 2004 (serial no. 108-143), 63-73, testimony of Janet Heinrich, on behalf of the Government Accountability Office (GAO);
15. House Committee on Government Reform, The Next Flu Pandemic: Evaluating U.S. Readiness, 109th Congress, 1st sess., June 30, 2005 (serial no. 109-49), 107-125, testimony of Marcia Crosse on behalf of the GAO, 2005;
16. G. Caleb Alexander, G. Luke Larkin, and Matthew K. Wynia, "Physicians' Preparedness for Bioterrorism and Other Public Health Priorities," Academic Emergency Medicine 13, no.11 (2006): 1238-1241, Epub 2006 Apr 13;
17. NGA Center for Best Practices, Pandemic Preparedness in the States: An Interim Assessment from Five Regional Workshops (Washington, DC: NGA, 2008), 1-2;
18. Trust for America's Health (TAH), Our Vision for a Healthier America (Washington, DC: TAH, 2008) (public statement signed by 121 health and community organizations: "[T]oday, serious gaps exist in the nation's ability to safeguard health, putting our families, communities, states and nation at risk"), http://healthyamericans.org/policy/files/ VisionHealthierAmerica. pdf (accessed April 6, 2008).
19. National Association of County and City Health Officials (NACCHO), Federal Funding for Public Health Emergency Preparedness: Implications and Ongoing Issues for Local Health Departments (Washington, DC: NACCHO, 2007);
20. IOM, Hospital-Based Emergency Care: At the Breaking Point (Washington, DC: National Academies Press, 2006), 201;
21. Jeanne Lambrew and Donna Shalala, "Federal Health Policy Response to Hurricane Katrina, What it Was and What it Could Have Been," JAMA 296 (2006): 1394-97;
22. Sara Rosenbaum, "US Health Policy in the Aftermath of Hurricane Katrina," JAMA 295 (2006): 437-39;
23. P. Gregg Greenough and Thomas D. Kirsch, "Hurricane Katrina: Public Health Response - Assessing Needs," NEJM 353 (2005): 1544-46;
24. Kaiser Family Foundation, Health Challenges for the People of New Orleans: The Kaiser Post-Katrina Baseline Survey (Washington, DC: Kaiser Family Foundation, 2007);
25. Centers for Disease Control and Prevention (CDC), Key Findings From Public Health Preparedness: Mobilizing State by State (Atlanta, GA: CDC, 2008), 5.
26. See, for example, Michael Osterholm, "Preparing for the Next Pandemic," New England Journal of Medicine (NEJM) 352 (2005): 1839-42;
27. Sarah A. Lister and Holly Stockdale, Pandemic Influenza: An Analysis of State Preparedness and Response Plans (Washington, DC: Congressional Research Service, 2007).
28. Association of State and Territorial Health Officials (ASTHO), State Public Health Employee Worker Shortage Report: A Civil Service Recruitment and Retention Crisis (Washington, DC: ASTHO, 2004), 2-3.
29. Heinrich, 2004 testimony, 63;
30. CDC, Public Health Preparedness: Mobilizing State by State (Atlanta, GA: CDC, 2008), 27;
31. NGA Center for Best Practices, Pandemic Preparedness in the States: An Interim Assessment from Five Regional Workshops (Washington, DC: NGA, 2008), 1-2;
32. NACCHO, Federal Funding;
33. Terri Rebmann et al., "Hospital Infectious Disease Emergency Preparedness: A Survey of Infection Control Professionals," American Journal of Infection Control 35, no.1 (2007): 25-32.
34. See also Bradford H. Gray and Kathy Hebert, After Katrina: Hospitals in Hurricane Katrina: Challenges Facing Custodial Institutions in a Disaster (Washington, DC: Urban Institute, 2006): 14-19;
35. American College of Emergency Physicians, The National Report Card on the State of Emergency Medicine (Washington, DC: American College of Emergency Physicians, 2006), 1-2;
36. Office of the Inspector General, Memorandum Report-Laboratory Preparedness for Pandemic Influenza (Washington, DC: Department of Health and Human Services, 2007), 1-2.
37. IOM, Future of Public Health, 144.
38. Future of Public Health, Ibid., 4-17.
39. American Medical Association (AMA), Resolution H-440.892, Bolstering Public Health Preparedness, Proceedings of the AMA House of Delegates, 2001 Interim Meeting, 389 (Chicago, IL: AMA);
40. AMA, Resolution H-440.954, Revitalization of Local Public Health Units for the Nation, Proceedings of the AMA House of Delegates, 2007 Annual Meeting, 399 (Chicago, IL: AMA);
41. AMA, H-440.982, Centers for Disease Control Funding, Proceedings of the AMA House of Delegates, 2005 Annual Meeting, 346 (Chicago, IL: AMA);
42. AMA, D-440.997, Support for Public Health, Proceedings of the AMA House of Delegates, 2003 Annual Meeting, 257 (Chicago, IL: AMA);
43. Coalition for Health Funding, "It's Time to Make Public Health Funding a National Priority" (Washington, DC: Coalition for Health Funding, 2008) (letter to members of Congress signed by more than 400 health organizations urging increased funding for function 550 programming in fiscal year 2009), http://www.aamc.org/advocacy/healthfunding/correspondence/ 021908.pdf (accessed April 6, 2008).
44. Congressional Budget Office (CBO), An Analysis of the President's Budgetary Proposals for Fiscal Year 2009, Budget Projections: supplemental data tables (Washington, DC: CBO, 2008): 4 [also incorporates unpublished data provided by CBO to us].
45. Statistical Abstract of the United States (Washington, DC: US Census Bureau, 2008).
46. CBO, Analysis of the President's Budgetary Proposals, 2008 (unpublished table).
47. CDC, National Health Expenditure Accounts: Definitions, Sources, and Methods 2006 (Washington, DC: Centers for Medicare and Medicaid Services, 2008).
48. Office of Management and Budget (OMB), Public Budget Database, February 2008, http://www.whitehouse.gov/omb/budget/fy2009/db.html (accessed July 25, 2008).
49. OMB, Fiscal Year 2009 President's Budget (Washington, DC: OMB, 2008), supplementary tables (table 27-1, historical tables 3.2, 8.7, 9.8, 12.2, 12.3).
50. DHHS, Budget in Brief (Washington, DC: DHHS, 1999), pp 18-44, 94-99;
51. DHHS, Budget in Brief (Washington, DC: DHHS, 2000), pp 21-50, 117-120;
52. DHHS, Budget in Brief (Washington, DC: DHHS, 2001), pp 15-50, 100;
53. DHHS, Budget in Brief (Washington, DC: DHHS, 2002), pp 15-47, 99-105;
54. DHHS, Budget in Brief (Washington, DC: DHHS, 2003), pp 10-38, 93-94;
55. DHHS, Budget in Brief (Washington, DC: DHHS, 2004), pp 12-40, 105-106;
56. DHHS, Budget in Brief (Washington, DC: DHHS, 2005), pp 12-42, 113;
57. DHHS, Budget in Brief (Washington, DC: DHHS, 2006), pp 16-40, 99-101;
58. DHHS, Budget in Brief (Washington, DC: DHHS, 2007), pp 15-39, 102-109;
59. DHHS, Budget in Brief (Washington, DC: DHHS, 2008), pp 14-40, 105-111.
60. GAO, Bioterrorism: Federal Research and Preparedness Activities (Washington, DC: GAO, September 2001), GAO-01-915.
61. Crystal Franco and Shana Deitch, "Billions for Biodefense: Federal Agency Biodefense Funding, FY2007-FY2008," Biosecurity and Bioterrorism 5 (2007): 117-133
62. Except where indicated, for prospective analysis we relied on unofficial baseline projections adjusted by the CBO to remove out-year supplemental funding otherwise required to be repeated in the official CBO baseline.
63. See Centers for Medicare & Medicaid Services (CMS), National Health Expenditure Data, http://www.cms.hhs.gov/NationalHealthExpendData (accessed April 6, 2008).
64. We obtained out-year projections (fiscal years 2010-2013) for the president's budget from unpublished CBO data tables associated with the March 2008 CBO reestimate of the president's fiscal year 2009 budget request.
65. See OMB, Budget of the United States Government, Fiscal Year 2009, http://www.whitehouse.gov/omb/budget/fy2009,
66. and OMB, Supplementals, Amendments and Releases, http://www.whitehouse. gov/omb/budget/amendments.htm (accessed April 6, 2008).
67. Note that much of our analysis focuses on budget function 550 (health) and budget subfunctions 551, 552, and 554. This budget function captures discretionary and mandatory federal expenditures for health care services (SF 551), health-related research and training programs (SF 552), and consumer and occupational health and safety programming (SF 554). CBO, Budget Options (Washington, DC: CBO, 2007), 145.
68. CMS, National Health Expenditure Accounts, 2008.
69. CBO, Analysis of the President's Budgetary Proposals, 3. For years after 2009, the President's budget is presented in less detail. For discretionary spending, the request for 2010 through 2013 is provided only in aggregate terms (which CBO used to calculate funding totals for defense and nondefense spending), and the budget does not contain year-by-year estimates of spending and revenues after 2013. It does, however, specify the total effect of proposed changes in laws affecting taxes and mandatory spending for the 10-year period through 2018. To determine the impact of the President's proposals, CBO, with assistance from JCT [the Joint Committee on Taxation], developed its own estimates for policies affecting revenues and mandatory spending. It estimated discretionary outlays for the 2014-2018 period by projecting the amount of discretionary budget authority that the President recommended for 2013 and adjusting that amount for inflation.
70. Note that $291 billion in supplemental and emergency discretionary funding for military operations in Iraq and Afghanistan and other activities related to the war on terrorism was appropriated in fiscal years 2006 and 2007 ($120 billion in 2006 and $171 billion in 2007). The president further requested supplemental and emergency funding totaling $193 billion in fiscal year 2008 (of which $88 billion had been appropriated as of this writing) and requested another $70 billion in fiscal year 2009. CBO, Budget and Economic Outlook: Fiscal Years 2008 to 2018 (Washington, DC: CBO, 2008), Box 1-1;
71. CBO, President's Budgetary Proposals, 17.
72. See Office of the Actuary, Projections of National Health Expenditures: Methodologies and Model Specification (Washington, DC: CMS, 2008), 14;
73. Office of the Actuary, National Health Expenditure Accounts, 14-15.
74. "Nussle Threatens Vetoes Before Dem Budgets Unveiled," Congress DailyPM, March 3, 2008.
75. National Health Expenditure (NHE) per capita estimates are roughly consistent with 2005 survey-derived state and local spending estimates in Leslie M. Beitsch et al., "Public Health at Center Stage: New Roles, Old Props," Health Affairs 25 (2006): 917-922
76. NGA and National Association of State Budget Officers (NASBO), The Fiscal Survey of the States: December 2007 (Washington, DC: NGA and NASBO, 2007), viii.
77. The Fiscal Survey of the States: December 2007 (2007), viii.Ibid.
78. Elizabeth C. McNichol and Iris J. Lav, 29 States Face Total Budget Shortfall of at Least $48 Billion in 2009(Washington, DC: Center on Budget and Policy Priorities, 2008), 3.
79. National Conference of State Legislators (NCSL), State Budget Update: April 2008 (Washington, DC: NCSL, 2008);
80. NCSL, Changes in State Tax Collections, 2000 to 2007, Quarterly (Washington, DC: NCSL, 2008);
81. Jennifer Steinhauer, "As the Economy Falters, So Do State Budgets," New York Times, sec. A, March 17, 2008;
82. Stan Dorn et al., Medicaid, SCHIP and Economic Downturn: Policy Challenges and Policy Responses (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, 2008).
83. NCSL, State Budget Update, 2008.
84. NCSL, State Budget Update: March 2007 (Washington, DC: NCSL, 2007), Tables 5 and 6, 18-23 (identifying probable use of unexpected resources in fiscal years 2007 and 2008);
85. NGA Center for Best Practices, The Governors Speak-2008: An Interim Report on the State-of-the-State Addresses of 25 Governors (Washington, DC: NGA, 2008), 9-10.
86. Within health care, governors significantly focused on coverage for the uninsured, health issues associated with children, and health care costs. Forty percent (10 of 25 governors) "highlighted wellness, prevention, and early intervention programs focused on promoting healthy lifestyles and detecting diseases and conditions early." GAO, State and Local Governments: Growing Fiscal Challenges Will Emerge During the Next 10 Years (Washington, DC: GAO, 2008), 5-6.
87. NCSL, State Budget Update, 2008, 1;
88. Lucy Dadayan and Robert B. Ward, "State Tax Revenue Weakens Still Further, While Costs Rise Sharply," State Revenue Report 72 (March 2008): 1.
89. Julie Gerberding, CDC, Professional Judgment [Budget] for Fiscal Year 2008, submitted to the US House Appropriations Subcommittee on Labor, Health, and Human Services, Education and Related Agencies, April 2007;
90. TAH, Ready or Not? Protecting the Public's Health from Diseases, Disasters and Bioterrorism (Washington, DC: TAH, 2007);
91. GAO, Influenza Pandemic: Further Efforts Are Needed to Ensure Clearer Federal Leadership Roles and an Effective National Strategy (Washington, DC: GAO, 2007);
92. GAO, Influenza Pandemic: Opportunities Exist to Address Critical Infrastructure Protection Challenges That Require Federal and Private Sector Coordination (Washington, DC: GAO, 2007); GAO, Letter Report to The Honorable Bennie G. Thompson et al., Subject: Public Health and Hospital Emergency Preparedness Programs: Evolution of Performance Measurement Systems to Measure Progress, March 23, 2007;
93. NACCHO, Federal Funding.
94. IOM, Future of Public Health, 143.
95. Thomas May and Ross Silverman, "Bioterrorism Defense Priorities," Science 301 (2003): 17.
96. TAH, Ready or Not?;
97. Aaron Katz, Andrea B. Staiti, and Kelly L. McKenzie, "Preparing for the Unknown, Responding to the Known: Communities and Public Health Preparedness," Health Affairs 24 (2006): 946-57;
98. Julie Gerberding, Professional Judgment;
99. CDC, Key Findings, 5.
100. Eric Lipton. "US Lists Possible Terror Attacks and Likely Toll," New York Times, sec. A, March 16, 2005.
101. CBO, President's Budgetary Proposals, Table 1-1
102. President's Budgetary Proposals, Ibid.
103. Sheryl Gay Stolberg, "Bush Presents Budget That Would Increase Deficit," New York Times, sec. A, February 5, 2008.
104. CBO, President's Budgetary Proposals, 17.
105. See Consolidated Appropriations Act, 2008, Public Law 110-161, 110th Cong., 1st sess. (December 26, 2007).
106. CBO, President's Budgetary Proposals, 16.
107. House Budget Committee, Hurricanes Katrina and Rita: What Will Be the Long-Term Effect on the Federal Budget, 110th Cong., 1st sess., August 2, 2007 (serial no. 110-18), 12-21, testimony of Stanley J. Czerwinski on behalf of the GAO;
108. House Budget Committee, The Growing Budgetary Costs of the Iraq War, 110th Cong., 1st sess., October 24, 2007 (serial no. 110-22), 9-22, testimony of Peter Orszag on behalf of the CBO.
109. CBO, Budget and Economic Outlook, Table 1-5. Table estimates were updated subsequent to publication by the CBO. Note that a more rapid force drawdown would incur a net savings in discretionary outlays relative to current baseline estimates (first scenario).
110. Budget and Economic Outlook, Ibid., Box 1-1;
111. CBO, President's Budgetary Proposals, 16.
112. See, for example, Anna Bernasek, "Economic View: 'Temporary' Tax Cuts Have a Way of Becoming Permanent," sec. B, New York Times, May 14, 2006.
113. Net total includes both Joint Committee on Taxation estimates of reduced revenues through fiscal year 2018 attributable to newly proposed changes to the tax code and increased mandatory outlays for refundable tax credits. CBO, President's Budgetary Proposals, 9.
114. Joint Committee on Taxation, Description of Revenue Provisions Contained in the President's Fiscal Year 2009 Budget Proposal (Washington, DC: Government Printing Office, 2008);
115. CBO, President's Budgetary Proposals, Table 1-3.
116. CBO, Budget and Economic Outlook, Table 1-5.
117. Budget and Economic Outlook, Ibid., Box 1-1
118. Paul A. Singer, "Hurricane Season: Port in a Storm," National Journal 38, no.21 (May 27, 2006): 1422-26; Czerwinski, testimony.
119. CBO, Budget and Economic Outlook, xi, 18.
120. GAO, Health Care Spending: Public Payers Face Burden of Entitlement Program Growth, While All Payers Face Rising Prices and Increasing Use of Services (Washington, DC: GAO, 2007).
121. Donna Stone et al. on behalf of the National Conference of State Legislatures, letter to the Honorable Harry Reid et al., January 18, 2008 ("[S]tates are facing budget challenges due to the slowing national economy . . . more [states] are expected to face serious budget gaps as they progress further into their fiscal years"); GAO, State and Local Governments.
122. NGA, Economic Stimulus: a State Perspective (Washington, DC: NGA, 2008), 1-2. ("Although the nation is at the beginning of a downturn, 17 states already face shortfalls totaling $14 billion in 2008 and 15 states project shortfalls of $30 billion for 2009. History suggests both the number of states facing shortfalls and the severity will grow even after the downturn ends.").
123. NGA and NASBO, Fiscal Survey of the States, viii;
124. NCSL, State Budget Update, 2008;
125. GAO, State and Local Governments;
126. GAO, State and Local Government Retiree Benefits: Current Funded Status of Pension and Health Benefits (Washington, DC: GAO, 2008).
127. NGA and NASBO, Fiscal Survey of the States, 5;
128. NGA, Policy Position EC-13: The Medicare Drug Benefit (Washington, DC: NGA, 2007), 13.2;
129. Senate Finance Committee, Covering Uninsured Children: the Impact of the August 17 CHIP Directive, 110th Cong., 2nd sess., April 9, 2008;
130. Alan R. Weil, testimony on behalf of the National Academy for State Health Policy; Vernon K. Smith, Barbara Coulter Edwards, and Jennifer Tolbert, Current Issues in Medicaid: A Mid-FY2008 Update Based on a Discussion with Medicaid Directors (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, 2008).
131. NCSL, State Budget Actions FY2006 and FY2007 (Washington, DC: NCSL, 2007);
132. GAO, State and Local Governments, 1-6.
133. "Nussle Threatens Vetoes," Congress DailyPM.
134. Campaign for Public Health, "CDC Director Again Calls for $15 Billion Agency Budget," Update (Winter 2008), http://www.fundcdc.org/ documents/CPHUpdateFinal1Q08. pdf (accessed July 25, 2008);
135. Centers for Disease Control and Prevention: Professional Judgment Budget for Fiscal Year 2006, submitted to the US House Appropriations Subcommittee on Labor, Health and Human Services, Education and Related Agencies, March 2006, 8.
136. See, for example, Bill Frist, "Public Health and National Security: The Critical Role of Increased Federal Support," Health Affairs 21 (2002): 117-30;
137. Joseph R. Biden, "America Is Not Ready to Respond to a National Health Emergency," The Hill, May 10, 2006.
138. Trust for America's Health, Our Vision for a Healthier America (Washington, DC: TAH, 2008), public statement signed by 121 health and community organizations, http://healthyamericans.org/policy/files/VisionHealthierAmerica. pdf (accessed April 6, 2008);
139. Coalition for Health Funding, It's Time to Make Public Health Funding a National Priority (Washington, DC: CHF, 2008), letter to members of Congress signed by more than 400 health organizations urging increased funding for function 550 programming in fiscal year 2009, http://www.aamc.org/advocacy/ healthfunding/correspondence/021908.pdf (accessed April 6, 2008);
140. Campaign for Public Health, letter to the Honorable David Obey et al. (sent to congressional appropriators from more than 400 health organizations urging increased funding for the CDC) (Washington, DC: CPH, 2007), http://www.fundcdc.org/documents/ PDFofFY08signonletterAppropsCommitteemembersFINAL- 000.pdf (accessed April 6, 2008).