Investing in ISSUE REPORT America’s Health: 2015 A STATE-BY-STATE LOOK AT PUBLIC HEALTH FUNDING AND KEY HEALTH FACTS APRIL 2015 Acknowledgements Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority. For more than 40 years the Robert Wood Johnson Foundation has worked to improve the health and health care of all Americans. We are striving to build a national Culture of Health that will enable all Americans to live longer, healthier lives now and for generations to come. For more information, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook. TFAH would like to thank RWJF for their generous support of this report. TFAH BOARD OF DIRECTORS Gail Christopher, DN Arthur Garson, Jr., MD, MPH President of the Board, TFAH Director, Health Policy Institute Vice President for Policy and Senior Advisor Texas Medical Center WK Kellogg Foundation John Gates, JD Cynthia M. Harris, PhD, DABT Founder, Operator and Manager Vice President of the Board, TFAH Nashoba Brook Bakery Director and Professor Octavio N. Martinez, Jr., MD, DPH, MBA, FAPA Institute of Public Health, Florida A&M University Executive Director Theodore Spencer Hogg Foundation for Mental Health at the Secretary of the Board, TFAH University of Texas at Austin Senior Advocate, Climate Center Tom Mason Natural Resources Defense Council President Robert T. Harris, MD Alliance for a Healthier Minnesota Treasurer of the Board, TFAH C. Kent McGuire, PHD Medical Director President and CEO North Carolina Medicaid Support Services Southern Education Foundation CSC, Inc. Eduardo Sanchez, MD, MPH David Fleming, MD Chief Medical Officer for Prevention Vice President American Heart Association PATH REPORT AUTHORS Jeffrey Levi, PhD. Laura M. Segal, MA Executive Director Director of Public Affairs Trust for America’s Health Trust for America’s Health and Professor of Health Policy Robyn Gougelet Milken Institute School of Public Health at the Government Relations Representative George Washington University Trust for America’s Health Rebecca St. Laurent, JD Consultant 2 TFAH • healthyamericans.org Investing in INTRODUCTION Introduction For too long, the country has focused on treating people after America’s they become sick instead of preventing diseases before they occur. Health Investing in disease prevention is the most effective, common-sense way to But, the public health system has been chronically underfunded for decades. Public Health improve health — helping to spare millions of Americans from developing Analyses from the Institute of Medicine (IOM), The New York Academy of Report preventable illnesses, reduce healthcare Medicine (NYAM), the U.S. Centers for series costs, and improve the productivity of Disease Control and Prevention (CDC), the American workforce so we can be and a range of other experts have found competitive with the rest of the world. that federal, state and local public health departments have been hampered due to Tens of millions of Americans are limited funds and have not been able to currently suffering from preventable adequately carry out many core functions, diseases such as cancer, heart disease and including programs to prevent disease diabetes. And, today’s children are in and prepare for health emergencies.1 danger of becoming the first generation in American history to live shorter, less In this report, the Trust for America’s healthy lives than their parents. Health (TFAH) examines public health funding in combination with key health Americans across the country deserve and facts in each state to further the discussion should expect basic health protections, about how to ensure public health is no matter where they live. Yet, disease funded sufficiently and structured as rates vary significantly from city-to-city and effectively as possible to have real impact region-to-region. And, fundamental pub- on improving health. The report: lic health services intended to protect our l rovides the public, policymakers and a P health and the funding of these programs often vary dramatically from state-to-state broad and diverse set of groups involved and among communities within states. in public health with an objective, Currently, there is no systematic rationale nonpartisan, independent analysis of the for ensuring a minimum level of health status of public health funding policies; services for all Americans, or that the l E ncourages greater transparency and money spent on public health programs accountability of the system; and is being used in the most effective ways to l R ecommends ways to assure the public reduce and prevent disease and injury. health system meets today’s needs and Public health departments have the works across boundaries to accomplish unique role and responsibility as chief its goals. health strategist for communities – work- Overall, Investing in America’s Health con- ing to improve health in schools, work- cludes that the public health system must places and neighborhoods. This involves be modernized — and that a sustained and identifying the top health problems and sufficient level of investment in preven- developing strategies for how to address APRIL 2015 tion is needed at all levels of government them. To be effective, public health of- to improve health in the United States. ficials must have the capabilities to define Improvements and closing the gaps in dif- the scope of health problems, set goals to ferences in disease rates will not be accom- improve health and recruit whoever can plished unless an adequate level of funding help make change happen. is provided to support public health. MAIN FINDINGS l N ational Public Health Funding: Combined person ($218 adjusted for inflation) com- federal, state and local public health spend- pared to $241 per person in 2009. Adjust- ing is below pre-recession levels — at ing for inflation, public health spending was $75.4 billion total in 2013 — or $239 per 10 percent lower in 2013 than in 2009.2 Governmental Public Health Expenditures 2003-13 $300 10% 8% $250 6% $200 4% 2% $150 0% $100 -2% –––- Per capita –––- $ -4% –––- Per capita real $ $50 ---- Annual growth rate, per capita nominal $ ---- Annual growth rate, per capita real $ -6% ---- Percent of national health expenditures $0 -8% 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Source: Author’s analysis of National Health Expenditure Accounts data Source: Public Health Economics l F lat Federal Funding: Federal fund- FY 2015. And the amount of federal ing for public health has remained at a funding spent to prevent disease and relatively flat level for years. The budget improve health in communities ranged for CDC has decreased from a high of significantly from state to state, with a $7.07 billion in FY 2005 to $6.93 billion per capita low of $15.14 in Indiana to a in FY 2015.3 Spending through CDC high of $50.09 in Alaska. averaged to only $20.01 per person in CDC Program Levels — Fiscal Year 2008 to Fiscal Year 2015* $7.00 $0.19 $0.61 $0.81 $0.83 $0.89 $0.46 $5.25 $200 (Billions) $6.05 $6.92 $6.75 $6.23 $6.06 $5.83 $6.02 $6.04 $3.50 $1.75 2008 2009** 2010 2011 2012 2013 2014 2015 Fiscal Year ■ CDC Funding from the Prevention and Public Health Fund ■ CDC Program level (Without the PPHF) *This chart does not account for inflation, numbers are rounded **FY2009 includes from the 2009 Recovery Act 4 TFAH • healthyamericans.org l C hronic Disease Increases Important But Insufficient: • he Prevention and Public Health T chronic diseases remain high and Fund (Prevention Fund) has provided require additional federal, state and increased support for evidence-based local resources to adequately fund prevention programs (since 2010), programs and services to show returns but rates of obesity, smoking and in reducing diseases. Chronic Disease Funding — Fiscal Year 2003 to Fiscal Year 2015* $1,500 $1,125 $59 $301 $411 $244 $457 $452 (Millions) $750 $790 $818 $900 $834 $825 $834 $882 $905 $774 $756 $740 $719 $747 $375 $0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Fiscal Year ■ Funding from the Prevention and Public Health Fund ■ Chronic Disease Discretionary level (Without the PPHF) *FY 2010-2015 values are supplemented by the Prevention and Public Health Fund l P ublic Health Emergency l C uts in State and Local Funding: At Preparedness Cuts: the state and local levels, public health • ublic Health Emergency Preparedness P budgets have been cut at drastic rates (PHEP) Cooperative Agreement Funding in recent years. According to a TFAH — which provides support for states analysis, 22 states and Washington, and localities to prepare for and re- D.C. decreased their public health spond to all types of disasters — has budgets from FY 2012-13 to FY 2013- dropped from a high of $919 million in 14. Budgets in 17 states decreased for FY 2005 to $643 million in FY 2015 two or more years in a row, and budgets in nine states decreased for three or • he Hospital Preparedness Program T more years in a row. In FY 2013-14, the (HPP) has been cut from a high of median state funding for public health $515 million in fiscal year 2004 to just was $31.06 per person, ranging from $255 million in FY 2015 a cut of more a high of $156.01 in Hawaii to a low than 50 percent, including a more than of $3.59 in Nevada. From FY 2008 to $100 million cut in FY 2014. The HPP FY 2014, the median per capita state provides grants and leadership to de- spending decreased from $33.71 to velop coalitions of healthcare facilities $31.06. This represents a cut of more to improve medical surge capacity and than $1.3 billion adjusted for inflation. enhance community and hospital pre- paredness for health emergencies. TFAH • healthyamericans.org 5 Percent of Adults Who Have Diabetes— l W ide Variation in Health Statistics by Population Health Institute, provide Alaska vs. West Virginia State: There are major differences in county-level data on a number of key disease rates and other health factors in health factors for nearly every county in 7.1% of adults in Alaska have diabetes states around the country. For instance, the country. The rankings assess health only 7.1 percent of adults in Alaska and behaviors (tobacco use, diet, alcohol Utah have diabetes compared to 13.8 use, etc.), clinical care (access to and 13.8% of adults in Alabama have diabetes percent in Alabama, and 27.3 percent quality of care), social and economic of adults in West Virginia are current factors (such as education, employment Percent of Adults Who are Smokers— smokers while only 10.3 percent report and income) and physical environment Kentucky vs. Utah smoking in Utah. (environmental quality and the built environment such as housing and Kentucky l W ide Variation in Health Statistics 27.3% transportation).  The Rankings highlight by County: There are also major Utah the healthiest and least healthy 10.3% differences in disease rates and health counties in every state and identify factors within each state. County factors that influence health, outside of Health Rankings, published by the the doctor’s office. The rankings do not Robert Wood Johnson Foundation currently include budget data by county. (RWJF) and University of Wisconsin ENSURING BASELINE PUBLIC HEALTH IN EVERY U.S. ZIP CODE: FOUNDATIONAL CAPABILITIES It is time to rethink key aspects of the menting them well. Achieving this goal country’s public health system. The will require restructuring public health Institute of Medicine, the Transforming programs — exploring new funding Public Health Project funded by the Rob- and business models that can assure ert Wood Johnson Foundation and other consistent resources are devoted to leading public health groups have called support these foundational capabilities. for reenergizing the public health system This can be achieved through new fund- around foundational capabilities that ing mechanisms or by giving states and ensure basic abilities are maintained localities more flexibility in exchange and sufficiently funded — while policies, for increased demonstration of capabili- programs, training and technologies can ties and accountability. Modernizing adapt to meet changing threats.4, 5 business practices and finding efficien- cies may require exploring innovative Prioritizing a set of foundational capa- approaches such as regionalization, bilities would help ensure the country increased healthcare and public health maintains a consistent baseline for pro- integration, public-private partnerships, tecting the public against both emerg- resource-sharing and working with Ac- ing and ongoing health threats. This countable Care Organizations (ACOs), or means focusing on the fundamental, within new and risk-sharing structures proven practices of health promotion and global health budgets. and disease prevention — and imple- 6 TFAH • healthyamericans.org SECTI O N 1: State Rates SECTION 1: FUNDING FOR PUBLIC HEALTH Funding for Public Health Public health programs are funded through a combination of and Trends federal, state and local dollars. Each level of government has different, significant delay from the time a President but important responsibilities for proposes a fiscal year budget to when protecting the public’s health. While appropriations legislation is signed into law this report focuses primarily on federal to the time when the funds are disbursed. funding to states, it also provides Thus in looking at federal public health information about state funding. funds that go to the states, TFAH uses FY 2014 data for this analysis, which is the most TFAH analyzes federal and state funding for recent budget year for which the data is public health based on the most complete most complete and accurate. financial data currently available. There is a A. FEDERAL INVESTMENTS IN PUBLIC HEALTH FEDERAL FUNDING FOR STATES FROM THE U.S. CENTERS FOR DISEASE CONTROL AND PREVENTION Katherine Welles / Shutterstock.com a katz / Shutterstock.com Approximately 75 percent of CDC’s Most of the federal funding from budget is distributed to states, localities, CDC is distributed by categories — for and other public and private partners to important, but often siloed, health support services and programs. concerns. Federal funding is based on a mixture of population-based formula These funds support a wide range of grant programs (often based on disease essential public health programs — to rates or other incidence formulas) improve health, prevent diseases and and a series of competitive grants - injuries and to prepare for major health where some states receive funding and APRIL 2015 emergencies. However, the current others do not due to insufficient funds. federal public health funding structure Because of federal funding limitations, does not actively promote a set of many states submit competitive grants baseline, consistent capabilities that that are “approved but unfunded” due every community across the country to limited funds. should be able to achieve. CDC FUNDING BY STATE 2014 Birth Defects, Health Reform - Health Agency for Toxic CDC-Wide Chronic Disease Emerging HIV/AIDS, Developmental Chronic Disease Reform - Toxic Substances and Activities Prevention and Zoonotic Environmental Viral Hepatitis, State Disabilities, Prevention Substances & Disease Registry and Program and Health Infectious Health STI and TB Disability and and Health Environmental (ATSDR) Support Promotion Diseases Prevention Health Promotion Public Health Alabama 1,669,697 2,679,308 12,902,069 855,765 24,000 9,835,523 Alaska 357,639 806,933 840,617 12,455,377 1,117,503 2,255,366 Arizona 298,981 620,431 1,844,968 13,032,152 1,600,420 572,880 9,081,193 Arkansas 374,054 1,469,141 1,379,539 9,809,207 1,008,688 3,991,922 California 789,040 3,732,277 11,164,599 61,471,451 7,394,091 4,203,255 1,255,000 99,468,487 Colorado 336,764 2,549,568 2,201,582 13,302,749 3,606,329 1,240,339 9,224,433 Connecticut 498,307 188,327 2,525,907 8,060,851 4,090,586 1,802,416 7,355,728 Delaware 394,477 286,674 8,717,616 658,012 102,113 2,651,101 D.C. 723,835 5,738,806 1,572,934 20,261,908 2,156,848 2,201,536 22,367,237 Florida 443,878 624,430 4,599,330 23,719,764 2,137,848 2,281,677 56,812,029 Georgia 375,802 1,609,947 7,197,605 32,991,404 5,444,031 2,179,065 26,969,865 Hawaii 220,901 1,214,074 8,294,064 777,984 515,000 3,339,494 Idaho 201,477 57,019 574,164 6,840,838 522,874 1,542,556 Illinois 1,680,405 5,904,145 3,845,374 27,090,756 3,908,895 1,727,015 29,398,022 Indiana 212,131 2,513,080 7,701,696 926,179 901,800 6,573,245 Iowa 2,269,999 1,696,511 9,223,864 1,769,137 1,149,864 2,575,322 Kansas 1,727,666 12,664,094 949,933 639,717 2,428,708 Kentucky 341,301 2,255,394 10,952,047 851,846 1,031,146 3,475,145 Louisiana 347,446 5,242,512 9,610,182 934,179 1,876,009 13,368,650 Maine 122,924 1,648,757 8,687,075 851,224 1,876,701 1,904,915 Maryland 3,858,540 3,148,027 22,508,449 4,670,672 2,599,055 23,699,185 Massachusetts 402,138 1,884,544 4,468,531 19,262,806 3,581,480 3,253,984 1,255,000 17,112,267 Michigan 440,581 1,524,500 6,810,122 29,805,746 2,123,566 1,876,371 13,970,238 Minnesota 451,912 356,399 4,204,729 18,615,370 6,023,124 2,573,577 7,220,704 Mississippi 116,032 2,253,384 10,874,985 829,889 183,148 7,976,671 Missouri 331,895 370,947 3,856,458 9,359,812 1,371,333 2,036,341 9,845,408 Montana 454,182 1,299,540 8,097,752 767,062 508,000 2,499,839 1,564,097 Nebraska 107,104 2,596,738 13,033,098 966,059 6,900 2,425,447 Nevada 473,425 606,639 8,930,803 709,964 10,000 4,133,316 New Hampshire 354,584 842,231 2,223,566 7,463,545 1,035,005 2,782,651 1,525,995 New Jersey 578,728 478,803 4,455,712 9,156,614 1,232,382 2,001,472 29,514,178 New Mexico 1,000,000 106,111 2,183,615 9,450,335 2,312,607 2,113,999 3,641,496 New York 826,102 4,556,975 11,165,935 40,650,466 7,865,195 4,845,641 96,943,339 North Carolina 320,138 3,454,560 4,447,090 19,450,241 1,482,105 512,522 16,499,007 North Dakota 455,703 394,511 4,845,488 667,138 5,000 1,317,948 Ohio 149,998 569,151 6,990,280 19,427,776 4,594,209 1,278,707 12,078,697 Oklahoma 477,750 1,444,677 12,534,902 829,726 582,266 4,258,909 Oregon 586,950 542,447 1,107,390 13,732,031 3,146,957 2,266,273 5,423,548 Pennsylvania 455,685 1,403,523 7,366,098 19,514,863 2,431,211 1,871,773 26,160,359 Rhode Island 637,169 733,643 9,459,691 1,017,094 1,291,717 2,934,746 South Carolina 150,000 4,387,272 1,900,192 15,918,459 1,242,040 750,390 10,585,334 South Dakota 138,550 358,699 7,682,784 715,531 10,000 1,354,233 Tennessee 277,550 2,408,219 2,505,510 9,043,732 5,084,128 645,939 10,506,281 Texas 542,173 740,553 6,268,434 17,632,688 2,047,231 310,669 2,500,997 50,058,883 Utah 222,845 750,021 1,494,846 13,147,945 1,540,649 2,362,697 2,494,410 Vermont 150,000 422,077 3,506,388 974,772 1,879,200 2,208,866 Virginia 351,292 106,650 3,372,805 18,569,701 1,697,306 1,788,088 13,698,484 Washington 533,600 243,107 1,544,578 21,623,561 1,770,574 1,427,733 15,989,581 West Virginia 1,388,611 9,528,710 926,821 210,480 1,994,971 Wisconsin 445,246 1,046,092 3,021,064 11,158,694 2,273,553 2,327,783 5,232,970 Wyoming 141,924 352,509 3,464,267 701,426 1,374,756 Grand Total 14,501,599 61,662,384 151,396,605 755,240,866 108,193,181 68,636,909 5,010,997 2,499,839 718,363,265 [Source: CDC. For a detailed list of references, see Investing in America’s Health at www.healthyamericans.org] 8 TFAH • healthyamericans.org National Immunization Public Health World Trade Injury Institute for Public Health CDC Per and Scientific Vaccines for Center Health CDC Per Capita State Prevention and Occupational Preparedness Grand Total Capita Respiratory Services Children Programs 2014 Control Safety and and Response Ranking Diseases (PHSS) (WTC) Health Alabama 3,646,671 598,333 1,608,821 9,275,797 321,771 57,386,155 100,803,910 $20.79 26 Alaska 2,805,090 779,576 115,302 4,373,966 239,747 10,758,940 36,906,056 $50.09 1 Arizona 5,790,241 1,164,497 885,511 12,208,367 587,091 80,382,894 128,069,626 $19.03 34 Arkansas 2,652,201 423,510 724,909 6,654,114 350,454 46,880,238 75,717,977 $25.53 14 California 27,827,270 6,159,589 9,457,267 62,473,892 1,196,775 423,344,051 719,937,044 $18.55 38 Colorado 6,029,473 3,032,862 5,140,176 9,998,933 360,088 44,409,953 101,433,249 $18.94 36 Connecticut 4,203,412 670,731 994,650 7,760,623 247,691 32,385,298 70,784,527 $19.68 31 Delaware 2,498,238 578,888 4,389,690 224,246 9,909,588 30,410,643 $32.50 4 D.C. 7,584,317 1,557,610 1,701,665 8,507,863 8,187,906 9,554,122 92,116,587 $139.81 N/A Florida 11,093,837 3,043,539 1,759,027 29,139,373 417,234 209,260,534 345,332,500 $17.36 43 Georgia 15,377,359 2,779,086 1,190,979 16,324,723 8,652,581 118,975,080 240,067,527 $23.78 17 Hawaii 2,305,386 540,825 4,886,947 466,741 14,677,105 37,238,521 $26.23 12 Idaho 2,284,328 707,037 5,028,347 302,135 16,223,549 34,284,324 $20.98 25 Illinois 12,548,405 3,486,024 2,493,580 27,212,373 596,315 126,411,429 246,302,738 $19.12 33 Indiana 4,162,862 1,402,464 297,801 11,593,046 363,627 63,249,685 99,897,616 $15.14 50 Iowa 5,975,943 1,377,787 5,201,984 7,061,211 477,607 26,888,950 65,668,179 $21.13 24 Kansas 5,259,419 950,238 6,921,859 427,128 23,184,027 55,152,789 $18.99 35 Kentucky 4,973,038 1,397,073 3,189,481 8,698,334 166,302 44,147,114 81,478,221 $18.46 40 Louisiana 2,211,097 924,742 175,615 9,142,513 1,019,008 64,026,582 108,878,535 $23.42 19 Maine 2,060,714 468,946 4,925,847 215,523 12,314,954 35,077,580 $26.37 11 Maryland 9,277,330 3,680,893 8,338,391 13,682,174 7,925,332 65,498,244 168,886,292 $28.26 10 Massachusetts 5,462,701 1,885,128 9,986,301 13,440,931 399,486 55,991,048 138,386,345 $20.52 27 Michigan 12,260,236 4,832,960 4,232,631 16,783,122 407,927 85,344,445 180,412,445 $18.21 42 Minnesota 8,940,671 1,260,380 5,167,158 11,398,228 312,741 41,881,679 108,406,672 $19.86 29 Mississippi 4,725,742 428,329 67,455 6,615,533 336,720 38,719,729 73,127,617 $24.42 16 Missouri 4,629,252 584,338 11,140,524 272,070 53,237,409 97,035,787 $16.00 45 Montana 1,090,888 302,806 98,824 4,142,346 209,312 8,381,542 29,416,190 $28.74 9 Nebraska 3,703,019 621,001 2,210,061 5,526,426 486,494 17,466,815 49,149,162 $26.12 13 Nevada 3,568,362 403,308 7,017,456 376,863 29,871,029 56,101,165 $19.76 30 New Hampshire 1,433,389 830,079 120,000 4,980,300 463,106 8,984,174 33,038,625 $24.90 15 New Jersey 7,801,247 1,271,580 632,573 15,845,833 497,218 64,737,388 999,675 139,203,403 $15.57 48 New Mexico 4,003,630 524,822 856,908 6,808,065 373,497 34,200,681 67,575,766 $32.40 5 New York 22,144,209 6,265,931 5,032,199 39,047,788 1,975,332 206,563,313 20,114,304 467,996,729 $23.70 18 North Carolina 6,107,469 4,646,443 2,951,278 15,219,724 239,971 106,830,269 182,160,817 $18.32 41 North Dakota 3,274,460 278,089 4,107,079 373,851 6,034,246 21,753,513 $29.42 8 Ohio 7,467,030 3,482,664 3,111,233 18,408,295 432,496 103,840,251 181,830,787 $15.68 47 Oklahoma 2,958,363 1,393,588 563,348 8,084,077 944,121 54,458,397 88,530,124 $22.83 21 Oregon 7,659,747 2,053,155 1,748,287 8,051,668 519,844 30,704,262 77,542,559 $19.53 32 Pennsylvania 10,076,334 4,957,435 1,858,564 19,603,017 598,675 102,749,567 199,047,104 $15.57 48 Rhode Island 2,856,453 1,643,392 4,512,116 383,791 10,123,715 35,593,527 $33.73 3 South Carolina 3,556,132 819,853 9,730,185 435,504 55,799,476 105,274,837 $21.78 22 South Dakota 1,161,373 286,369 4,150,932 278,294 9,284,479 25,421,244 $29.80 7 Tennessee 6,536,511 1,855,942 162,638 11,044,268 521,947 70,363,950 120,956,615 $18.47 39 Texas 19,842,231 3,248,622 4,364,128 37,940,151 494,505 364,044,963 510,036,228 $18.92 37 Utah 2,582,349 1,868,259 1,582,920 7,010,496 521,396 24,153,950 59,732,783 $20.30 28 Vermont 1,565,401 197,379 4,024,418 422,210 5,998,085 21,348,796 $34.07 2 Virginia 7,625,285 2,194,317 83,271 17,457,338 7,199,549 59,792,631 133,936,717 $16.09 44 Washington 9,709,796 2,129,272 7,166,768 12,594,537 648,251 75,620,063 151,001,421 $21.38 23 West Virginia 1,609,719 1,640,306 323,000 5,428,268 303,291 19,963,685 43,317,862 $23.41 20 Wisconsin 9,978,578 919,432 1,995,984 11,440,453 685,515 41,610,736 92,136,100 $16.00 45 Wyoming 1,551,170 202,865 4,099,542 250,412 5,627,196 17,766,067 $30.41 6 U.S. TOTAL 326,448,378 88,752,294 97,590,688 615,913,108 54,109,691 3,292,247,666 21,113,979 6,381,681,449 $20.01 TFAH • healthyamericans.org 9 FEDERAL FUNDING FOR STATES FROM THE HEALTH RESOURCES AND SERVICES ADMINISTRATION The Health Resources and Services Administration (HRSA) The bulk of HRSA funds are in its two largest programs, the distributes approximately 90 percent of its funding in grants to community and migrant health centers and the Ryan White Act states and territories, public and private healthcare providers, HIV programs, and these dollars are awarded on a competitive health professions training programs and other organizations.6 basis and/or based on disease burden. HRSA’s funding is not distributed on a strictly per capita basis. FY 2014 HRSA Grants to States by Key Program Area (Selected Programs) HRSA Per Maternal & Child HRSA Total HRSA Per Capita State Primary Health Care Health Professions HIV/AIDS Capita Total Health (All Programs) Ranking (All Programs) Alabama $65,389,587 $21,434,165 $24,894,605 $30,755,777 $145,353,257 $29.97 16 Alaska $53,025,593 $1,292,505 $4,261,804 $2,758,178 $64,380,629 $87.39 1 Arizona $60,458,194 $11,261,206 $23,356,638 $26,621,768 $125,190,281 $18.60 43 Arkansas $39,493,547 $9,490,664 $16,509,391 $9,838,327 $78,552,343 $26.48 21 California $426,569,877 $77,295,438 $76,353,192 $286,978,798 $876,823,829 $22.60 32 Colorado $80,527,319 $12,393,081 $20,863,443 $27,010,201 $146,577,293 $27.37 18 Connecticut $39,220,809 $8,714,479 $17,005,938 $27,186,170 $92,705,342 $25.78 22 Delaware $10,696,918 $3,628,820 $7,961,352 $6,354,647 $29,565,685 $31.60 13 D.C. $16,639,949 $22,340,992 $23,011,644 $56,113,832 $120,015,099 N/A* N/A* Florida $174,888,478 $23,228,613 $32,591,560 $240,115,388 $473,892,558 $23.82 29 Georgia $81,995,511 $16,514,574 $26,649,444 $89,982,711 $219,686,152 $21.76 33 Hawaii $34,436,613 $7,273,108 $5,495,754 $2,954,956 $52,560,558 $37.03 7 Idaho $31,006,886 $1,380,917 $8,437,747 $3,285,209 $45,944,064 $28.11 17 Illinois $145,969,147 $25,324,774 $42,170,327 $90,742,688 $309,544,271 $24.03 26 Indiana $44,951,137 $7,899,946 $27,768,202 $17,221,765 $101,668,568 $15.41 47 Iowa $29,351,080 $5,087,281 $16,866,808 $5,755,304 $61,088,420 $19.66 38 Kansas $27,176,136 $3,885,586 $9,236,304 $4,988,136 $50,635,370 $17.44 45 Kentucky $51,531,617 $7,010,717 $23,115,114 $13,083,143 $101,007,687 $22.89 30 Louisiana $65,045,375 $14,142,889 $26,299,820 $50,458,532 $159,930,514 $34.40 8 Maine $29,783,110 $3,010,729 $14,103,948 $2,938,454 $53,814,050 $40.46 3 Maryland $49,528,333 $6,308,889 $31,511,386 $54,363,043 $143,257,287 $23.97 27 Massachusetts $89,191,598 $32,112,845 $39,490,427 $44,624,872 $207,601,413 $30.78 15 Michigan $86,543,844 $29,539,604 $38,392,943 $30,900,165 $194,266,891 $19.60 39 Minnesota $30,274,286 $8,849,552 $22,132,494 $15,297,302 $83,800,725 $15.36 48 Mississippi $58,723,210 $2,738,360 $17,783,895 $17,433,647 $99,229,216 $33.14 11 Missouri $73,865,808 $20,401,342 $27,978,561 $28,582,364 $155,248,877 $25.60 23 Montana $29,845,891 $3,776,082 $9,672,125 $1,862,028 $50,167,502 $49.01 2 Nebraska $15,849,182 $4,972,982 $8,132,220 $3,514,725 $35,312,073 $18.77 42 Nevada $13,582,454 $2,521,085 $5,781,591 $16,035,676 $39,907,179 $14.06 50 New Hampshire $17,753,733 $2,062,229 $7,748,972 $1,813,595 $32,013,121 $24.13 25 New Jersey $60,067,107 $5,969,034 $27,916,631 $85,823,163 $180,760,498 $20.22 35 New Mexico $56,675,744 $5,277,325 $12,511,620 $5,791,182 $82,855,412 $39.73 5 New York $185,711,009 $38,896,521 $57,196,096 $331,733,144 $617,852,877 $31.29 14 North Carolina $90,887,434 $17,623,919 $29,244,369 $57,846,038 $200,852,555 $20.20 36 North Dakota $6,459,500 $2,611,645 $3,490,408 $700,222 $18,085,886 $24.46 24 Ohio $92,806,132 $37,927,403 $34,832,158 $36,931,468 $206,883,631 $17.84 44 Oklahoma $38,347,845 $7,894,063 $18,835,334 $10,329,109 $77,610,174 $20.01 37 Oregon $68,673,355 $4,392,480 $18,846,937 $12,980,428 $108,364,262 $27.29 19 Pennsylvania $90,252,859 $66,770,835 $47,750,428 $82,280,913 $291,976,507 $22.83 31 Rhode Island $18,991,506 $2,197,351 $9,230,262 $5,351,992 $36,279,514 $34.38 9 South Carolina $67,016,210 $3,621,427 $24,344,718 $32,725,475 $130,295,411 $26.96 20 South Dakota $15,132,492 $2,084,804 $5,796,409 $1,300,515 $27,178,813 $31.86 12 Tennessee $61,893,934 $20,982,133 $26,064,746 $44,852,049 $156,541,772 $23.90 28 Texas $196,093,378 $42,053,859 $59,102,544 $156,731,241 $457,929,116 $16.99 46 Utah $25,319,784 $7,147,895 $21,311,442 $6,761,683 $62,144,852 $21.12 34 Vermont $14,745,565 $1,734,027 $4,245,163 $1,422,201 $23,561,826 $37.60 6 Virginia $64,587,425 $11,808,093 $24,467,383 $51,033,629 $156,386,451 $18.78 41 Washington $93,645,035 $21,082,592 $23,042,886 $95,128,776 $237,896,869 $33.69 10 West Virginia $48,370,888 $3,452,880 $15,849,330 $3,369,860 $74,116,062 $40.06 4 Wisconsin $30,900,969 $13,463,832 $22,860,706 $13,812,641 $85,225,434 $14.80 49 Wyoming $6,735,601 $483,341 $1,911,958 $974,362 $11,305,762 $19.35 40 U.S. TOTAL $3,306,628,994 $713,368,913 $1,144,429,177 $2,247,451,492 $7,593,843,938 $23.44 N/A* *D.C. was not included in the per capita rankings because total funding for D.C. includes funds for a number of national organizations. **The US total reflects HRSA grants to all states and D.C. [Source: HRSA. For a detailed list of references, see Investing in America’s Health at www.healthyamericans.org] 10 TFAH • healthyamericans.org THE PREVENTION AND PUBLIC HEALTH FUND The Prevention and Public Health Fund strategies to improve health. The Fund — an integral part of CDC’s budget has the support of more than 900 and programs — enables communities national, state and local organizations. around the country to invest in proven Prevention and Public Health Fund Allocations (FY 2010 to 2022) Current Funding Under P.L. 112-96 vs. Funding by P.L. 110-48 (ACA) $2.00 $2.00 $2.00 $2.00 $2.00 $2.00 $2.00 $2.00 $2.00 $1.75 $1.50 $1.50 $1.25 $1.25 (Dollars in billions) $1.00 $1.00 $.051 $.072 $.073 $.75 $0.75 $.50 $0.50 $.949 $.928 $.927 $882 $1.00 $1.25 $1.25 $1.50 $1.50 $0.25 $0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 ■ Under P 112-96 (Current Level) .L. ■ CMS Health Insurance Enrollment Support ($322 million) ■ Sequestration ■ Statutory Levels Under P 110-48 (ACA) .L. CDC Prevention and Public Health Fund Per Capita Allocations by State (FY 14)* (numbers are rounded) $2.32 $8.42 $7.43 $2.55 $2.84 CT: $1.61 $2.33 NH: $4.27 $2.19 $4.10 $2.44 $2.15 $4.95 MA: $2.30 $2.82 RI: $9.30 $2.47 $1.36 $1.98 $4.90 $1.06 $1.76 VT: $4.71 $3.26 $1.23 $1.88 $1.82 DC: $5.91 $1.02 $4.39 $1.08 $1.54 $1.45 DE: $8.73 $1.46 $1.27 MD: $2.75 $1.27 $3.37 $1.86 $2.30 $2.19 NJ: $1.04 $2.74 $2.07 $1.52 $1.96 $0.75 Over $5.01 $7.03 $0.68 $2.51 – $5.00 $1.51 – $2.50 $5.13 Under $1.50 *Per capita calculations do not include grants to National Organizations TFAH • healthyamericans.org 11 PREVENTION FUND: SNAPSHOT OF SOME KEY PROGRAMS Preventive Health and Health Services Block Grant Tips from Former Smokers Campaign l rovides every state with flexible support to address what P l E vidence-based tobacco education campaign — has helped 1.6 they determine to be their most important health needs. million Americans attempt to quit and 100,000 to successfully l B lock grant funds have doubled from $80 million in fiscal year quit immediately. It has led to a 12 percent increase in quit 2013 to $160 million in fiscal years 2014 and 2015 under attempts and prevented more than 17,000 premature deaths. the Prevention Fund. l R OI: $480 spent per quitter with a $2,800 return in premature death averted. Childhood Immunization Grant Program (Section 317) National Breast and Cervical Cancer Early Detection Program l 210 million of funding from Prevention Fund provides support for $ l 104 million from the Fund to help provide support in all 50 $ children to receive all recommended vaccinations on schedule. states to support screening for uninsured or underinsured l upports registries, surveillance, outreach and vaccine services. S women and help provide follow-up services as needed. State Public Health Actions to Prevent and Control Diabetes, State and Local Public Health Actions to Prevent Obesity, Heart Disease, Obesity and Related Risk Factors and Promote Diabetes, and Heart Disease and Stroke (1422 awards) School Health (“1305” awards) l our-year project to create community strategies to promote F l rovides $33 million in funds to enhance key chronic disease P health and integrate with health care systems. prevention programs in states. l $ 69.5 million given to 17 states and four large cities. l S upports cross-cutting approaches to prevent risk factors that contribute to chronic diseases. State Healthcare-Associated Infection (HAI) Prevention Program Epidemiology and Laboratory Capacity (ELC) Grants l 12 million from Fund supports coordination between public $ l$ 40 million from Fund supports improving a state’s ability to health and healthcare systems to reduce HAIs — helping to detect, diagnose and contain disease outbreaks. identify problem areas and improve prevention efforts. l S upports 460 full- and part-time highly expert jobs, and mod- ern scientific equipment. Million Hearts Campaign Workplace Wellness l 4 million from Fund supports national initiative aimed at pre- $ l$ 10 million from Fund providing support to help employers venting 1 million heart attacks and strokes by 2017. implement practice-based strategies to support health in the workplace and surrounding communities to lead to measurable health improvements. Fall Prevention Grants Garrett Lee Smith Youth Suicide Prevention Grants l 5 million from Fund aimed at evidence-based community $ l$ 12 million to expand program to 12 additional grantees for programs to reduce falls, the leading cause of fatal and non- education, training, screening, hotlines and support services fatal injuries in seniors. to prevent youth suicides. l A wards to 14 states and localities. Racial and Ethnic Approaches to Community Health (REACH) Good Health and Wellness in Indian Country l 30 million from Fund — $50.05 million total — supports $ l$ 11 million from Fund for 22 grants to prevent and manage 39 grants for culturally-tailored, evidence-based strategies to heart disease, diabetes and associated risk factors in Ameri- reduce health disparities at the community level. can Indian tribes and Alaskan Native villages. 12 TFAH • healthyamericans.org B. STATE INVESTMENT IN PUBLIC HEALTH State Public Health Budgets Nominal FY 2013-2014 FY 2013-2014 Per State Rank (Not Adjusted for Inflation) Capita Hawaii $219,042,777 $156.01 1 New York $2,144,180,554 $109.11 2 Alaska $77,613,600 $105.58 3 District of Columbia $67,202,000 $103.96 4 Idaho $143,890,100 $89.25 5 California $2,484,860,000 $64.82 6 North Dakota $46,001,508 $63.59 7 West Virginia $111,761,920 $60.27 8 Alabama $286,261,887 $59.22 9 Massachusetts $376,797,663 $56.30 10 Wyoming $31,693,243 $54.39 11 Rhode Island $53,281,186 $50.67 12 New Mexico $100,120,700 $48.01 13 Arkansas $141,876,132 $47.94 14 Tennessee $285,610,100 $43.97 15 Oklahoma $168,215,000 $43.69 16 Delaware $39,703,400 $42.89 17 Colorado $223,789,365 $42.48 18 Nebraska $74,670,172 $39.96 19 Vermont $24,657,900 $39.35 20 Washington $262,623,500 $37.67 21 Maryland $215,592,000 $36.36 22 Virginia $290,405,109 $35.16 23 Kentucky $142,051,439 $32.32 24 South Dakota $26,291,465 $31.12 25 MEDIAN $31.06 Connecticut $111,695,871 $31.06 26 Utah $85,514,900 $29.48 27 New Jersey $230,549,000 $25.91 28 Illinois $308,700,900 $23.96 29 Texas $589,908,925 $22.30 30 Montana $22,495,177 $22.16 31 Michigan $212,403,700 $21.46 32 Maine $27,469,065 $20.68 33 South Carolina $98,131,352 $20.55 34 Florida $376,397,399 $19.25 35 Iowa $58,263,068 $18.85 36 Georgia $184,693,477 $18.48 37 New Hampshire $21,579,046 $16.31 38 Oregon $62,720,932 $15.96 39 Louisiana $71,532,451 $15.46 40 Pennsylvania $193,901,000 $15.18 41 Ohio $168,783,566 $14.59 42 Minnesota $77,344,000 $14.27 43 Indiana $85,946,625 $13.08 44 Wisconsin $74,823,300 $13.03 45 Kansas $36,179,733 $12.50 46 Mississippi $36,739,194 $12.28 47 North Carolina $115,532,335 $11.73 48 Arizona $55,640,800 $8.40 49 Missouri $34,248,229 $5.67 50 Nevada $10,005,244 $3.59 51 [Source: TFAH analysis. For a detailed methodology, see Investing in America’s Health at www.healthyamericans.org] TFAH • healthyamericans.org 13 Every state allocates and reports its budget State funding ranges dramatically, often in different ways. States also vary widely related to the different structures of a in the budget details they provide. This state’s public health department. Some makes comparisons across states difficult. departments are centralized, while others For this analysis, TFAH examined state are decentralized wherein responsibilities budgets and appropriations bills for the rest more on local departments than at the agency, department, or division in charge state level. However, states and localities of public health services for FY 2012-13 also place different priorities on public and FY 2013-14, using a definition as health, which also accounts for differences consistent as possible across the two in funding. The state-by-state comparisons years, based on how each state reports included in this report’s budget analysis data. TFAH defined “public health do not include county or city revenues services” broadly, including most state- that are generated to support local health level health funding. departments, which are also quite variable. C. LOCAL INVESTMENT IN PUBLIC HEALTH There are approximately 2,800 local and, correspondingly, the way resources health departments in the United are determined and allocated differs States serving a diverse assortment significantly. A 2008 study found that of populations ranging from less median local public health spending than 1,000 residents in some rural was $29.57 per capita in 2005, while jurisdictions to around eight million funding ranged from an average of $8 people, as in the case of the New York per person in the lowest 20 percent of City Department of Health.7 Local communities to nearly $102 per person health departments (LHDs) are in the top 20 percent of communities.8 structured differently in each state A July 2011 study in Health Affairs found and may be centralized, decentralized that increased spending by local public or have a mixed function. Therefore, health departments can save lives the level of responsibility and services currently lost to preventable illnesses.9 provided by LHDs varies dramatically, 14 TFAH • healthyamericans.org SECTI O N 2: Key Health SECTION 2: KEY HEALTH FACTS Key Health Facts ADULT HEALTH INDICATORS U.S. Total State with State with Facts Highest/Worst Lowest/Best Massachusetts % Uninsured, All Ages (2013) 14.5% Texas (22.1%) (3.7%) AIDS Cumulative Cases Aged 13 and Older New York North Dakota 1,161,609 (2012 Yr End) (199,548) (187) California Alzheimer’s Estimated Cases among 65+ (2025) 6,479,700 Alaska (7,700) (660,000) Tennessee % Asthma Prevalence (2010) 13.5% Hawaii (17.6%) (9.3%) California Cancer Estimated New Cases (2014) 1,665,540 D.C. (2,840) (171,730) New Hampshire Chlamydia Rates per 100,000 Population (201) 446.6 D.C. (1,014.4) (236.2) Alabama Colorado Diabetes, % Adults (2013) N/A (13.8%) (6.5%) Fruits and Vegetables Intake, % who consume fruit West Virginia N/A D.C. (25.6%) and vegetables 5+ times daily (2011) (7.9%) AK, DE, HI, ME, Human West Nile Virus Cases (as of 12/16/14) 2,085 California (780) NH, NC, RI, VT, WV (0) West Virginia Hypertension, % Adults (2013) N/A Utah (24.2%) (41.0%) MS and WV Colorado Obesity, % Adults (2013) N/A (35.1%) (21.3%) Mississippi Colorado Physical Inactivity, % Adults (2013) N/A (38.1%) (17.9%) % Pneumococcal Vaccination Rates 65 and Over New Jersey 69.5% Oregon (75.6%) (2013) (61.9%) West Virginia % Seasonal Flu Vaccination Rates 65 and Over (2013) 65.0% Nevada (53.6%) (75.4%) Syphilis Rates per 100,000 Population (2013) 5.5 D.C. (26.6) Wyoming (0.2) West Virginia % Tobacco Use – Current Smokers (2013) 19.0% Utah (10.3%) (27.3%) California Tuberculosis Number of Cases (2013) 9,582 Wyoming (0) (2,171)  CHILD HEALTH INDICATORS Massachusetts % Uninsured, under 18 (2013) 7.1% Nevada (14.9%) (1.5%) AIDS Cumulative Cases Under Age 13 (2012 Yr End) 9,377 New York (2,431) ND and WY (2) Nebraska % Asthma – High School Students (2012) N/A Hawaii (30.1%) (16.9%) Fruit Indicator - % High School Students (2013) N/A Alabama (24.0%) Utah (34.3%) New High School Dropout Rate (2011-2012) 3.3% Alaska (7.0%) Hampshire (1.3%) Immunization Gap, % Children Aged 19-35 Months Arkansas Rhode Island 27.4% Without All Immunizations (2013) (39.4%) (15.5%) Infant Mortality – Per 1,000 Live Births Mississippi 6.2 Alaska (3.8) (2010 Final Data) (9.7) Mississippi % Low Birthweight Babies (2013 Final Data) 8.0% Alaska (5.8%) (11.5%) Obesity, % High School Students (2013) N/A Kentucky (18.0%) Utah (6.4%) Mississippi Obesity, % 10 to 17 Year Olds (2011) N/A Oregon (9.9%) APRIL 2015 (21.7%) Mississippi Pre-Term Births % of lie births (2013 Final Data) 11.4% Vermont (8.1%) (16.6%) Tobacco: % Current Smokers High School West Virginia N/A Utah (4.4%) Students (2013) (19.6%) South Carolina New Mexico Vegetable Indicator - % High School Students (2013) N/A (9.7%) (17.5%) Source: CDC. For a detailed list of references, see Investing in America’s Health at www.healthyamericans.org S EC T I ON 3 : Recommendations SECTION 3: RECOMMENDATIONS Recommendations America’s future economic well-being is inextricably tied to our health. High rates of preventable diseases are one of the biggest drivers of healthcare costs in the country. And, right now, Americans are not as healthy and productive as they could or should be to compete in the global economy. The nation’s public health system is Public Health Fund is used to build responsible for keeping Americans healthy upon — and expand not supplant — and safe. Public health is devoted to existing efforts. The Prevention Fund preventing disease and injury. If we kept is the nation’s largest single investment Americans healthier, we could significantly in prevention, using evidence-based drive down trips to the doctor’s office or and innovative partnership approaches emergency room, reduce healthcare costs to improve the health of Americans. and improve productivity. Without a strong investment in prevention, we will never advance in the In addition to shoring up the core fight to prevent diseases, curb the obesity ongoing funds for public health, we epidemic or reduce smoking rates. need to ensure the Prevention and APRIL 2015 TFAH recommends that: l C ore funding for public health — at l S table, sufficient, dedicated funding the federal, state and local levels — be is needed to support public health increased. emergencies and major disease outbreaks — so the country is not l T he first dollars of core funding caught unprepared for threats ranging should be used to assure that all from Ebola to an act of bioterror Americans are protected by a set of — and is better equipped to reduce foundational public health capabilities ongoing threats such as the flu, and services no matter where they live. foodborne illness and the measles. For this to be accomplished, these Currently, inadequate and fluctuating capabilities must be fully funded, and resources have left gaps in the ability funding should be tied to achieving to quickly detect, diagnose, treat and and maintaining these capabilities. contain the spread of illnesses. l F unding be considered strategically l A ccountability must be at the — so funds are used efficiently to cornerstone of public health funding. maximize effectiveness in lowering Americans deserve to know how disease rates and improving health. effectively their tax dollars are used, l T he Prevention Fund should be fully and the government’s use of funds allocated to support evidence-based should be transparent and clearly and innovative approaches to improve communicated with the public. the public health system and reduce disease rates. TFAH • healthyamericans.org 17 Endnotes 1 nstitute of Medicine. The Future of the I 6 ealth Resources and Services Administra- H Public’s Health in the 21st Century. Wash- tion. “About HRSA.” U.S. Department of ington, D.C, 2003. U.S. Centers for Disease Health and Human Services. http://www. Control and Prevention. Public Health’s hrsa.gov/about/default.htm. (accessed Infrastructure — A Status Report. Atlanta, January 23, 2008). Georgia, 2001. Trust for America’s Health. 7 eyer J. and Weiselberg L. “County and M Blueprint for a Healthier America: Modernizing City Health Departments: The Need for Sus- the Federal Public Health System to Focus on Pre- tainable Funding and the Potential Effect vention and Preparedness. 2008. of Healthcare Reform on their Operations.” 2 ays, G. “National Public Health Spend- M Health Management Associates, A Report ing: Still Waiting for Recovery.” In Public for the Robert Wood Johnson Foundation Health Economics. January 6, 2015. http:// and the National Association of County & publichealtheconomics.org/2015/01/06/ City Health Officials. December 2009. national-public-health-spending-still-wait- 8 ays GP and Smith SA. “Geographic Vari- M ing-for-recovery/ (accessed March 2015). ation in Public Health Spending,” 2009. 3 Adjusted for inflation. 9 ays GP and Smith SA. Evidence Links M 4 nstitute of Medicine. For the Public’s I Increases in Public Health Spending to De- Health: Investing in a Healthier Future. clines in Preventable Deaths. Health Affairs, Washington, D.C.: National Academies 30(8): 1585-1593, 2011. Press, April 2012. 5 ESOLVE. Transforming Public Health: R Emerging Concepts for Decision Making in a Changing Public Health World. 2012. 18 TFAH • healthyamericans.org TFAH • healthyamericans.org 19 1730 M Street, NW, Suite 900 Washington, DC 20036 (t) 202-223-9870 (f) 202-223-9871