Investing in ISSUE REPORT America’s Health: 2016 A STATE-BY-STATE LOOK AT PUBLIC HEALTH FUNDING AND KEY HEALTH FACTS APRIL 2016 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. TFAH would like to thank RWJF for their generous support of this report. TFAH BOARD OF DIRECTORS Gail Christopher, DN David Fleming, MD President of the Board, TFAH Vice President Vice President for Policy and Senior Advisor PATH 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 C. Kent McGuire, PHD Natural Resources Defense Council President and CEO Robert T. Harris, MD Southern Education Foundation Treasurer of the Board, TFAH Eduardo Sanchez, MD, MPH Medical Director Chief Medical Officer for Prevention North Carolina Medicaid Support Services American Heart Association CSC, Inc. REPORT AUTHORS REPORT CONTRIBUTOR Richard Hamburg Kevin McIntyre Interim President and CEO Government Relations Associate Trust for America’s Health Trust for America’s Health Laura M. Segal, MA Director of Public Affairs Trust for America’s Health Alejandra Martín, MPH Health Policy Research Manager Trust for America’s Health 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 officials must have the capabilities to Public Health most effective, common-sense way to define the scope of health problems, improve health — helping to spare set goals to improve health and recruit Report millions of Americans from developing whoever can help make change happen. preventable illnesses, reduce healthcare But, the public health system has been series costs and improve the productivity of chronically underfunded for decades. the American workforce so we can be Analyses from the Institute of Medicine competitive with the rest of the world. (IOM), The New York Academy of Tens of millions of Americans are Medicine (NYAM), the U.S. Centers currently suffering from preventable for Disease Control and Prevention diseases such as cancer, heart disease (CDC) and a range of other experts and type 2 diabetes. And, today’s have found that federal, state and local children are in danger of becoming public health departments have been the first generation in American hampered due to limited funds and history to live shorter, less healthy lives have not been able to adequately carry than their parents. out many core functions, including programs to prevent diseases and Americans across the country deserve prepare for health emergencies.1, 2, 3 and should expect basic health protections, no matter where they live. Investments in public health are essential Yet, disease rates vary significantly from for tackling the biggest health problems city to city and region to region. And, facing the country. They help prepare fundamental public health services — for and control emerging and persistent intended to protect our health — and threats, from the Zika virus to the the funding of these programs often Middle Eastern Respiratory Syndrome vary dramatically from state-to-state (MERS) to antibiotic resistance to the and among communities within states. dramatic rise in prescription painkiller Currently, there is no systematic rationale and heroin use to contaminated water for ensuring a minimum level of health and other sources of lead poisoning in services for all Americans or that the communities to obesity and tobacco use money spent on public health programs and related chronic diseases. Public is being used in the most effective way to health must constantly adapt to changes reduce and prevent disease and injury. in trends. For example, after years of public health and medical advances Public health departments have a unique contributing to longer life expectancies, role and responsibility as chief health there has been a significant rise in strategist for communities — working to deaths among middle aged men in the APRIL 2016 improve health in schools, workplaces past 15 years relating to increases in and neighborhoods. This involves drug and alcohol poisonings, suicides, identifying the top health problems and chronic liver disease and cirrhosis.4 developing strategies for how to address them. To be effective, public health According to CDC, most infectious Investing in America’s Health: diseases and a majority of chronic l rovides the public, policymakers and a P diseases could be prevented — sparing broad and diverse set of groups involved millions unnecessary suffering and in public health with an objective, saving billions in healthcare costs. nonpartisan, independent analysis of the In fact, an analysis by the Trust for status of public health funding policies; America’s Health (TFAH) found that an l E ncourages greater transparency and investment of $10 per person per year accountability of the system; and in proven evidenced-based community prevention programs that increase l R ecommends ways to assure the public physical activity, improve nutrition and health system meets today’s needs and prevent smoking and other tobacco use works across boundaries to accomplish could save the country more than $16 its goals. billion annually within five years — a Overall, Investing in America’s Health return of $5.60 for every $1 invested.5 concludes that the public health In this report, the Trust for America’s system must be modernized — and Health examines public health funding that a sustained and sufficient level of in combination with key health facts investment in prevention is needed at all in each state to further the discussion levels of government to improve health about how to ensure public health in the United States. Improvements and is funded sufficiently and structured closing the gaps in differences in disease as effectively as possible to have real rates will not be accomplished unless an impact on improving health. adequate level of funding is provided to support public health. 4 TFAH • healthyamericans.org MAIN FINDINGS Governmental Public Health Expenditures 2003-13 $300 10% l N ational Public Health Funding: 8% Public health spending is still below $250 6% pre-recession levels. A review in the American Journal of Public Health $200 4% found that in the last seven years, the 2% combined federal, state and local public $150 0% health spending per person has declined $100 -2% from $281 per person in 2008 (2014 –––- Per capita $ dollars) to $255 per person in 2014, -4% –––- Per capita real $ $50 ---- Annual growth rate, per capita nominal $ decreasing by approximately 9 percent.6 ---- Annual growth rate, per capita real $ -6% ---- Percent of national health expenditures According to the Centers for Medicare and $0 -8% 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Medicaid Services (CMS), the nation’s Source: Author’s analysis of National Health Expenditure Accounts data Source: Public Health Economics, 2015 health spending is projected to grow in the next 10 years, an average rate of 6 percent per year. This is due to the rapid growth in prescription drug spending, U.S. Public Health Expenditures in Dollars per Capita and as Percentage of health insurance expansions, cost sharing National Health Expenditure (NHE): 1960-2023 in insurance plans and an increase of 300 3.5 baby-boomers’ enrollment into Medicare.7 At the same time, public health’s share 250 3 of the total health spending is projected 2.5 $ Per Capita 200 Percentage to decrease to 2.4 percent — declining 2 25 percent when the share peaked at 3.2 150 1.5 percent in 2002.8 The diminishing share 100 $ per capita (inflation adjusted) is due to funding not keeping up with 1 Percentage of NHE inflation, federal budget sequestration and 50 0.5 cutting or defunding different public health 0 0 programs and services, often as a result 0 3 6 9 2 5 8 1 4 7 0 3 6 9 2 5 8 1 4 7 0 3 6 6 6 6 7 7 7 8 8 8 9 9 9 9 0 0 0 1 1 1 2 2 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20 of discretionary budget caps enacted Year under the Budget Control Act. Source: American Journal of Public Health, 2016 TFAH • healthyamericans.org 5 l F lat Federal Funding: Federal funding CDC Program Levels — Fiscal Year 2008 to Fiscal Year 2016* for public health has remained relatively $8.00 level for years. The budget for CDC has $0.19 decreased from a high of $7.07 billion $0.61 $0.89 $0.81 $0.83 $0.89 in fiscal year (FY) 2005 to $6.34 billion $6.00 $0.46 in FY 2016, approximately $600 million less than FY 2015.9 Spending through $4.00 (Billions) CDC averaged $21.31 per person in $6.05 $6.92 $6.75 $6.23 $6.06 $5.83 $6.02 $6.04 $6.28 FY 2016. And the amount of federal funding spent to prevent disease and $2.00 improve health in communities ranged significantly from state to state, with a per capita low of $15.99 in Indiana and $0 2008 2009** 2010 2011 2012 2013 2014 2015 2016 a high of $53.06 in Alaska. Variations in Fiscal Year the federal support for states is largely ■ CDC Funding from the Prevention and Public Health Fund ■ CDC Program Level (Without the PPHF) related to the differences in competitive *This chart does not account for inflation, numbers are rounded grants awarded to the states. **FY 2009 includes the 2009 Recovery Act l C hronic Disease Increases Important Chronic Disease Funding — Fiscal Year 2003 to Fiscal Year 2016* But Insufficient: $1,500 • he Prevention and Public Health T Fund (Prevention Fund) has provided $1,125 increased support for evidence-based $59 $301 $411 $244 $457 $452 $339 (Millions) prevention programs (since fiscal year $750 2010) — but rates of obesity, smoking and chronic diseases remain high and $790 $818 $900 $834 $825 $834 $882 $905 $774 $756 $740 $719 $747 $838 require additional federal, state and $375 local resources to adequately fund programs and services to show returns $0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 in reducing diseases. Fiscal Year ■ Funding from the Prevention and Public Health Fund ■ Chronic Disease Discretionary Level (Without the PPHF) *FY 2010-2016 values are supplemented by the Prevention and Public Health Fund 6 TFAH • healthyamericans.org • acial and Ethnic Approaches to R disparities — has dropped from $64 Community Health (REACH) funding — million in FY 2012 to $51 million in FY which provides support to community 2016. Rates of chronic disease, such level programs that are culturally-tailored as cancer, heart disease and diabetes, and evidence-based to reduce health remain high among these populations. REACH Funding — Fiscal Year 2007 to Fiscal Year 2016 $60 $40.00 $30.00 $30.00 $30.00 $45 FUnding Level (in millions) $25.00 $30 $15 $33.64 $33.86 $35.64 $39.27 $14.02 $13.94 $13.22 $20.00 $20.95 $20.95 $0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Fiscal Year ■ Discretionary Funding ■ Prevention and Public Health Fund • DC Division of Nutrition, Physical C increased in FY 2016 to $50 million but Activity, and Obesity (DNPAO) funding remains insufficient to combat the obe- — which promotes healthy eating and sity epidemic occurring in this country. active living for children and adults — CDC Division of Nutrition, Physical Activity, and Obesity Fiscal Year 2007 to Fiscal Year 2016 $50 $49.92 $44.30 $44.99 $10.00 $10.00 $42.19 $38 $40.59 $35.00 $35.00 $34.19 $34.00 (Dollars in millions) $8.82 $25 $32.23 $13 $12.58 $0 $2.50 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Fiscal Year ■ Discretionary Funding ■ Prevention and Public Health Fund TFAH • healthyamericans.org 7 Only 7.1 percent of adults in l P ublic Health Emergency ($33.71), however adjusting for inflation, Utah have diabetes compared Preparedness Cuts: this represents a cut of $1.2 billion. • ublic Health Emergency Preparedness P to 14.1 percent in West Virginia. l W ide Variation in Health Statistics (PHEP) Cooperative Agreement Funding by State: There are major differences — which provides support for states in disease rates and other health fac- and localities to prepare for and re- tors in states around the country. For Percent of Adults Who are Smokers— West Virginia vs. Utah spond to all types of disasters — has instance, only 7.1 percent of adults in dropped from a high of $940 million in Utah have diabetes compared to 14.1 West Virginia 27.3% FY 2002 to $651 million in FY 2016. percent in West Virginia, and only 10.3 Utah percent of adults in Utah are current 10.3% • he Hospital Preparedness Program T (HPP) has been cut from a high of smokers while 27.3 percent of adults $515 million in FY 2004 to $255 report smoking in West Virginia. million in FY 2016, a cut of more than l W ide Variation in Health Statistics by 50 percent including a more than County: There are also major differ- $100 million cut in FY 2014. The ences in disease rates and health fac- HPP provides grants and leadership tors within each state. County Health to develop coalitions of healthcare Rankings, published by the Robert Wood organizations to prepare the Johnson Foundation (RWJF) and Uni- healthcare system to respond to and versity of Wisconsin Population Health recover from health emergencies. Institute, provide county-level data on a l C uts in State and Local Funding: Ac- number of key health factors for nearly cording to a TFAH analysis, 16 states every county in the country. The rank- decreased their public health budgets ings assess health behaviors (tobacco from FY 2013-14 to FY 2014-15. Bud- use, diet, alcohol use, etc.), clinical care gets in six states — Alabama, Indiana, (access to and quality of care), social Kansas, North Carolina, Ohio and Okla- and economic factors (such as educa- homa — decreased for three or more tion, employment and income) and physi- years in a row. In FY 2014-15, the cal environment (environmental quality median state funding for public health and the built environment such as hous- was $35.77 per person — up from the ing and transportation). The Rankings FY 2013-2014 level of $31.06 — rang- highlight the healthiest and least healthy ing from a low of $4.10 in Nevada to a counties in every state and identify fac- high of $158.30 in Hawaii. The median tors that influence health, outside of the per capita state spending in FY 2015 doctor’s office. The rankings do not cur- is around the same rate as in FY 2008 rently include budget data by county. 8 TFAH • healthyamericans.org ENSURING BASELINE PUBLIC HEALTH IN EVERY U.S. ZIP CODE: FOUNDATIONAL CAPABILITIES Americans across the country deserve bilities could be given greater flexibility in and should expect basic health protec- their use of federal support for core public tions, no matter where they live. Yet, health functions. The ability to carry out disease rates vary significantly from foundational capabilities is contingent on city to city and region to region. And, having a trained, expert workforce, mecha- fundamental public health services — nisms for continuous quality improvement intended to protect our health — and and stable, sufficient funding. The defined the funding of these programs often foundational capabilities include: vary dramatically from state-to-state and l A ssessment (surveillance, epidemiology among communities within states. and laboratory capacity); The Institute of Medicine and leading l D eveloping policy to effectively pro- experts, including the Public Health mote and improve health; Leadership Forum, have called for set- l U sing integrated data sets for assess- ting a stronger baseline standard set of ment, surveillance and evaluation to cross-cutting “foundational capabilities” identify crucial health challenges, best for public health departments to then practices and better health; be able to better carryout the “founda- l C ommunicating with the public and other tional services” of: 1) communicable/ audiences to disseminate and receive infectious disease prevention; 2) chronic health-related information in an effective disease and injury prevention; 3) environ- manner, including health promotion oppor- mental public health; 4) maternal, child tunities, access to care and prevention; and family health; and 5) access to and linkage with clinical care.10, 11 l M obilizing the community and forging partnerships to leverage resources This approach means changing siloed (including funding); grant and budget structures that often l B uilding new models that integrate fund different aspects of these core capa- clinical and population health; bilities separately. For instance, current grants for epidemiological, laboratory and l C ultivating leadership — along with or- surveillance support are administered ganization, management and business separately and are also divided by grants — skills needed to build and sustain for diseases or conditions they are work- an effective health department and ing to prevent or control — rather than workforce to effectively and efficiently contributing to increasing the performance promote and improve health; of an overall integrated, coordinated sys- l D emonstrating accountability for what tem. A foundational capabilities model governmental public health does directly includes the ability and flexibility for health and for those things that it oversees departments and community partners to through accreditation, continuous quality build upon core capabilities to meet their improvement and transparency; and specific needs and concerns — contingent l P rotecting the public in the event of on additional available resources. For an emergency or disaster, as well as instance, jurisdictions that demonstrate responding to day-to-day challenges or their ability to meet the foundational capa- threats, with a cross-trained workforce. TFAH • healthyamericans.org 9 EXAMPLES OF STATES ADOPTING FOUNDATIONAL CAPABILITIES A number of states, including Colorado, Health estimated it would require an ad- Oklahoma and Washington, have taken ditional $21.8 million (2013 dollars) — steps to move toward a foundational and local health jurisdictions in the state capabilities approach within state and would need an additional $99.9 million local public health departments. (2013 dollars) — to fully and effectively implement foundational capabilities.12 For instance, in Washington state, they have: engaged stakeholders (such as Ohio has also been developing strate- hospitals, community health organiza- gies for implementing foundational tions, service providers and laboratories) capabilities, and has moved forward to to partner with public health depart- consolidate some local health depart- ments to improve or increase health ments and cross-jurisdictional services information exchange; reviewed state and programs and to prioritize funding public health laws to identify governing streams.13, 14 Colorado legally defined power and regulations across jurisdic- foundational “minimum quality stan- tions; reviewed funding streams to dards,” and within two years has shown determine what mandatory services may significant increases in the delivery of or may not be attached to funding; identi- several program and service areas.15 fied which services can be provided by The Public Health Cost Estimation Work state health departments versus local Group has developed a methodology to health departments; and engaged with help state and local health departments policy makers to gain support of legisla- determine the cost of adopting founda- tive changes needed to fully develop and tional capabilities, and the data will be implement foundational public health used to generate national estimates.16, 17 services. The state’s Department of 10 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, available. There is a significant delay but important, responsibilities for from the time a President proposes a protecting the public’s health. While fiscal year budget to when appropriations this report focuses primarily on federal legislation is signed into law to the time funding to states, it also provides when the funds are disbursed. Thus in information about state funding. looking at federal public health funds that go to the states, TFAH uses FY 2015 TFAH analyzes federal and state funding data for this analysis, which is the most for public health based on the most recent budget year for which the data is complete financial data currently most complete and accurate. A. FEDERAL INVESTMENTS IN PUBLIC HEALTH FEDERAL FUNDING FOR STATES FROM THE U.S. CENTERS FOR DISEASE CONTROL AND PREVENTION Katherine Welles / 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 2016 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 applications that are “approved but every community across the country unfunded” due to limited funds. should be able to achieve. CDC FUNDING BY STATE 2015 Birth Defects, Health Agency for Toxic CDC-Wide Chronic Disease Emerging HIV/AIDS, Developmental Ebola Reform - Toxic Substances and Activities Prevention and Zoonotic Environmental Viral Hepatitis, State Disabilities, Response and Substances & Disease Registry and Program and Health Infectious Health STI and TB Disability and Preparedness Environmental (ATSDR) Support Promotion Diseases Prevention Health Public Health Alabama $1,770,279 $2,411,588 $12,830,858 $2,886,905 $959,399 $9,638,919 Alaska $357,639 $731,933 $646,544 $11,015,311 $2,060,480 $1,192,723 $2,287,923 Arizona $428,973 $892,396 $1,928,186 $12,761,669 $3,353,906 $2,077,288 $702,988 $9,341,745 Arkansas $374,054 $1,937,058 $1,463,357 $9,055,038 $3,823,882 $1,025,970 $3,932,665 California $789,039 $3,083,358 $10,569,631 $58,616,382 $18,410,031 $7,840,093 $4,401,882 $103,399,245 Colorado $359,652 $3,590,447 $2,000,008 $11,067,169 $4,520,199 $4,714,637 $1,122,726 $12,494,210 Connecticut $642,277 $166,484 $2,203,907 $7,057,347 $5,944,528 $3,979,360 $1,789,485 $7,245,729 Delaware $412,739 $389,143 $9,099,461 $2,501,728 $734,024 $102,113 $2,414,577 D.C. $477,116 $4,604,503 $2,973,424 $19,649,713 $4,916,473 $1,820,321 $2,954,094 $22,343,198 Florida $593,878 $711,987 $4,616,503 $23,145,521 $8,211,759 $2,452,027 $1,891,776 $55,798,420 Georgia $215,805 $2,561,094 $7,344,422 $37,067,391 $14,515,760 $6,039,329 $1,887,144 $26,954,295 Hawaii $237,797 $1,300,218 $8,177,277 $1,728,796 $850,238 $515,000 $2,942,635 Idaho $201,477 $130,153 $683,765 $6,886,179 $2,048,064 $595,279 $1,552,279 Illinois $1,417,116 $6,037,813 $3,643,654 $29,707,236 $14,489,750 $3,364,165 $1,654,875 $30,424,643 Indiana $170,920 $2,466,644 $7,563,919 $3,770,599 $1,179,272 $1,022,575 $6,218,195 Iowa $2,119,997 $1,775,497 $7,419,061 $5,718,442 $1,823,838 $891,901 $2,253,338 Kansas $1,426,049 $12,784,599 $2,413,326 $1,100,825 $686,622 $2,404,008 Kentucky $319,315 $2,143,099 $10,941,600 $4,145,258 $986,577 $940,480 $3,843,299 Louisiana $324,105 $5,506,942 $10,211,199 $4,017,241 $1,242,542 $2,024,633 $16,341,880 Maine $144,875 $1,363,424 $8,529,393 $1,908,041 $1,293,238 $1,580,937 $1,608,146 Maryland $4,567,513 $3,148,495 $21,452,338 $13,728,111 $8,905,679 $2,598,440 $26,768,575 Massachusetts $402,138 $1,788,317 $5,168,071 $19,959,103 $6,736,296 $3,757,174 $3,133,315 $17,350,222 Michigan $440,581 $1,675,000 $6,646,974 $27,665,661 $5,088,078 $2,236,346 $1,865,680 $14,602,688 Minnesota $451,912 $789,930 $3,976,626 $18,996,395 $7,706,439 $7,532,340 $2,402,515 $6,648,124 Mississippi $111,345 $2,321,667 $11,998,970 $3,346,530 $802,373 $133,306 $7,193,126 Missouri $331,895 $913,270 $3,790,191 $9,199,118 $3,751,551 $1,252,440 $2,024,432 $10,093,392 Montana $452,868 $1,130,142 $7,943,498 $2,268,991 $828,139 $478,341 $2,499,995 $1,480,840 Nebraska $113,272 $138,143 $2,545,524 $11,564,850 $5,133,426 $1,073,482 $12,089 $2,370,454 Nevada $468,813 $716,113 $9,109,367 $3,734,690 $789,971 $375,004 $4,181,590 New Hampshire $354,584 $563,317 $2,291,718 $6,709,301 $2,129,261 $1,266,367 $2,618,926 $1,330,402 New Jersey $578,728 $921,838 $4,379,893 $8,364,552 $7,382,753 $1,223,206 $2,052,499 $28,151,318 New Mexico $1,360,000 $73,289 $2,264,761 $8,644,948 $2,595,147 $2,396,788 $1,890,238 $3,624,373 New York $826,166 $4,882,665 $10,987,209 $41,361,839 $15,986,126 $8,747,102 $4,933,314 $97,424,368 North Carolina $320,138 $3,652,220 $4,094,772 $19,461,269 $6,908,879 $1,435,283 $925,366 $14,120,259 North Dakota $455,582 $504,547 $4,825,414 $1,795,447 $666,113 $1,294,238 Ohio $615,424 $6,989,632 $18,806,863 $6,454,634 $5,149,647 $1,107,092 $13,200,208 Oklahoma $327,750 $1,539,651 $11,314,392 $2,285,356 $834,827 $276,357 $4,395,414 Oregon $436,965 $549,994 $1,191,719 $14,415,789 $4,991,482 $4,239,717 $2,234,736 $4,964,171 Pennsylvania $605,685 $1,210,523 $7,346,401 $18,475,758 $9,702,875 $2,945,004 $1,808,891 $24,846,858 Rhode Island $606,000 $833,217 $11,480,618 $2,122,262 $1,215,391 $1,267,610 $2,824,683 South Carolina $4,353,080 $2,075,176 $15,218,639 $4,415,979 $1,365,787 $750,078 $10,232,265 South Dakota $119,066 $352,638 $8,089,923 $1,997,647 $693,667 $1,359,560 Tennessee $277,550 $868,107 $2,570,161 $9,123,282 $5,240,607 $5,369,239 $531,401 $12,770,383 Texas $542,173 $1,079,794 $6,338,584 $17,912,328 $12,680,593 $2,141,478 $389,850 $53,255,565 Utah $222,845 $1,104,505 $1,588,534 $12,951,745 $6,123,227 $1,913,383 $2,371,877 $2,258,977 Vermont $150,000 $534,054 $4,305,430 $2,047,764 $944,312 $1,944,952 $1,814,906 Virginia $374,192 $143,337 $3,598,240 $19,064,601 $7,052,252 $2,307,475 $1,491,502 $14,837,498 Washington $533,600 $255,926 $1,672,449 $22,780,006 $4,911,570 $2,181,662 $1,351,683 $13,596,002 West Virginia $1,471,870 $7,786,088 $2,801,286 $1,123,412 $285,256 $1,906,159 Wisconsin $445,246 $1,296,631 $3,055,241 $11,356,399 $3,627,974 $2,476,516 $2,217,954 $4,607,152 Wyoming $141,924 $346,458 $3,382,636 $1,534,211 $914,385 $1,416,521 Grand Total $14,474,696 $64,223,424 $152,326,733 $747,307,443 $277,666,612 $123,999,850 $67,641,935 $2,499,995 $728,359,640 *D.C. was not included in the per capita rankings because total funding for D.C. includes funds for a number of national organizations. [Source: CDC. For a detailed list of references, see Investing in America’s Health at www.healthyamericans.org] 12 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 2015 Control Safety and and Response Ranking Diseases (PHSS) (WTC) Health Alabama $6,009,310 $519,245 $1,425,070 $8,978,187 $356,232 $58,178,726 $105,964,718 $21.81 29 Alaska $4,262,694 $767,824 $76,000 $4,409,734 $319,953 $11,048,760 $39,177,518 $53.06 1 Arizona $7,785,334 $2,063,685 $555,791 $11,969,905 $286,008 $86,914,667 $141,062,541 $20.66 33 Arkansas $3,457,634 $375,261 $724,063 $6,627,030 $269,637 $44,949,668 $78,015,317 $26.20 16 California $32,908,277 $7,081,252 $7,877,467 $62,352,748 $1,228,086 $440,536,989 $759,094,480 $19.39 40 Colorado $8,427,751 $2,982,114 $6,100,092 $10,074,639 $610,588 $46,649,063 $114,713,295 $21.02 32 Connecticut $6,797,102 $611,593 $609,202 $7,969,828 $388,109 $31,548,344 $76,953,295 $21.43 30 Delaware $1,840,222 $564,030 $4,386,406 $162,348 $10,380,250 $32,987,041 $34.87 4 D.C. $7,501,291 $2,313,984 $1,638,059 $16,429,475 $8,910,058 $10,695,247 $107,226,956 $159.51 N/A* Florida $11,005,623 $2,612,442 $1,902,058 $29,145,563 $457,955 $230,090,124 $372,635,636 $18.38 43 Georgia $18,409,852 $2,200,551 $1,586,085 $16,806,886 $7,240,501 $122,022,753 $264,851,868 $25.93 17 Hawaii $2,133,351 $556,086 $4,980,373 $279,014 $14,928,986 $38,629,771 $26.98 14 Idaho $2,270,063 $681,099 $274,493 $5,081,187 $185,002 $20,478,037 $41,067,077 $24.81 21 Illinois $11,703,373 $4,231,859 $2,532,491 $26,924,395 $562,390 $124,041,174 $260,734,934 $20.27 35 Indiana $4,733,919 $1,300,078 $402,241 $11,711,000 $478,072 $64,809,156 $105,826,590 $15.99 50 Iowa $3,717,420 $1,342,000 $4,783,444 $6,907,749 $446,162 $28,973,159 $68,172,008 $21.82 28 Kansas $2,917,287 $843,033 $7,076,470 $475,257 $25,698,992 $57,826,468 $19.86 39 Kentucky $4,713,881 $3,602,545 $3,230,653 $8,693,723 $208,299 $46,772,306 $90,541,035 $20.46 34 Louisiana $2,584,657 $849,731 $371,423 $9,207,811 $996,310 $69,926,849 $123,605,323 $26.46 15 Maine $2,147,295 $446,966 $4,870,894 $251,518 $12,683,526 $36,828,253 $27.70 12 Maryland $11,658,124 $4,262,113 $8,279,505 $13,180,523 $10,663,793 $64,070,958 $193,284,167 $32.18 7 Massachusetts $5,724,123 $1,711,807 $10,678,767 $13,490,495 $439,755 $61,196,321 $151,535,904 $22.30 26 Michigan $10,768,848 $4,012,034 $3,308,835 $16,968,014 $475,825 $87,596,102 $183,350,666 $18.48 42 Minnesota $7,679,530 $1,172,619 $4,468,130 $11,204,874 $422,487 $44,022,330 $117,474,251 $21.40 31 Mississippi $3,274,438 $379,230 $130,000 $6,576,603 $252,384 $40,557,819 $77,077,791 $25.76 18 Missouri $6,753,631 $612,658 $50,935 $11,026,945 $137,988 $55,483,447 $105,421,893 $17.33 44 Montana $2,115,708 $286,434 $209,231 $4,171,259 $358,499 $10,261,677 $34,485,622 $33.39 5 Nebraska $2,740,909 $1,362,031 $1,657,430 $5,490,781 $402,143 $17,930,349 $52,534,883 $27.71 11 Nevada $4,489,536 $358,623 $6,956,558 $283,390 $32,450,885 $63,914,540 $22.11 27 New Hampshire $2,705,411 $1,197,472 $145,000 $4,969,302 $278,848 $9,421,811 $35,981,720 $27.04 13 New Jersey $6,184,268 $1,076,193 $357,633 $15,839,133 $310,145 $71,317,278 $999,725 $149,139,162 $16.65 48 New Mexico $3,849,516 $1,369,884 $636,913 $7,000,177 $271,066 $30,230,275 $66,207,375 $31.75 9 New York $22,821,976 $5,252,984 $5,898,697 $37,840,571 $1,810,969 $222,032,546 $22,026,517 $502,833,049 $25.40 19 North Carolina $6,227,285 $4,912,939 $2,513,086 $14,683,349 $447,437 $109,210,815 $188,913,097 $18.81 41 North Dakota $1,716,191 $266,959 $4,132,516 $243,935 $6,149,661 $22,050,603 $29.13 10 Ohio $8,415,323 $3,920,871 $2,584,868 $18,154,399 $461,392 $107,801,454 $193,661,807 $16.68 47 Oklahoma $3,207,119 $1,741,422 $563,513 $7,801,393 $701,741 $54,140,932 $89,129,867 $22.79 23 Oregon $5,362,714 $2,801,101 $2,348,759 $8,271,687 $308,591 $38,246,733 $90,364,158 $22.43 25 Pennsylvania $13,055,151 $5,634,613 $2,853,417 $19,245,119 $523,392 $106,336,474 $214,590,161 $16.76 46 Rhode Island $1,602,722 $2,964,242 $527,661 $4,502,689 $364,917 $11,118,822 $41,430,834 $39.22 3 South Carolina $3,869,669 $743,319 $9,900,616 $271,679 $56,743,745 $109,940,032 $22.45 24 South Dakota $2,261,898 $212,897 $4,032,866 $249,851 $9,207,702 $28,577,715 $33.29 6 Tennessee $9,056,722 $2,219,173 $292,283 $11,141,416 $407,291 $72,184,201 $132,051,816 $20.01 37 Texas $21,394,808 $2,719,170 $3,958,884 $37,897,120 $379,118 $387,002,866 $547,692,331 $19.94 38 Utah $4,003,518 $2,394,925 $1,476,000 $7,084,411 $407,650 $27,005,636 $70,907,233 $23.67 22 Vermont $1,374,174 $1,138,340 $4,203,797 $304,742 $6,576,478 $25,338,949 $40.47 2 Virginia $9,189,827 $1,649,877 $83,271 $18,869,781 $5,771,388 $57,460,257 $141,893,498 $16.93 45 Washington $7,556,959 $1,729,202 $6,531,273 $12,389,206 $459,767 $68,666,979 $144,616,284 $20.17 36 West Virginia $3,490,581 $1,542,009 $820,046 $5,524,252 $198,404 $18,921,442 $45,870,805 $24.87 20 Wisconsin $8,761,706 $1,765,976 $1,890,399 $11,509,822 $484,867 $41,166,576 $94,662,459 $16.40 49 Wyoming $1,293,206 $192,665 $4,123,867 $202,356 $5,156,617 $18,704,846 $31.91 8 U.S. TOTAL $347,931,927 $97,549,160 $96,353,168 $622,787,544 $52,407,309 $3,430,995,964 $23,026,242 $6,849,551,642 $21.31 N/A TFAH • healthyamericans.org 13 FEDERAL FUNDING FOR STATES FROM THE HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA) HRSA distributes approximately 90 percent of its funding in per capita basis. The bulk of HRSA funds are in its two largest grants to states and territories, public and private healthcare programs, the community and migrant health centers and the providers, health professions training programs and other Ryan White Act HIV programs, and these dollars are awarded organizations.18 HRSA’s funding is not distributed on a strictly on a competitive basis and/or based on disease burden. FY 2015 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 $82,783,920 $22,484,349 $19,560,509 $27,769,878 $155,409,758 $31.98 17 Alaska $68,526,048 $2,529,518 $6,838,688 $2,556,039 $82,859,237 $112.21 1 Arizona $74,659,171 $10,620,012 $25,761,636 $25,751,895 $140,209,893 $20.53 44 Arkansas $51,362,908 $10,612,519 $19,292,440 $10,506,038 $94,818,935 $31.84 18 California $591,614,266 $85,482,904 $79,083,906 $283,785,337 $1,048,556,760 $26.79 29 Colorado $98,483,850 $15,598,922 $23,516,389 $24,085,511 $166,478,433 $30.51 20 Connecticut $52,285,573 $14,074,792 $17,645,804 $26,012,151 $110,392,687 $30.74 19 Delaware $12,838,892 $4,776,909 $3,734,974 $6,370,592 $27,892,965 $29.49 22 D.C. $25,157,424 $19,425,336 $20,646,440 $64,648,379 $131,356,297 N/A* N/A* Florida $218,252,548 $26,779,240 $42,148,410 $226,080,901 $518,852,495 $25.60 32 Georgia $108,471,540 $19,258,217 $36,302,385 $107,156,732 $275,438,189 $26.96 27 Hawaii $39,234,358 $9,936,587 $13,731,567 $2,737,977 $68,514,564 $47.86 4 Idaho $45,123,583 $3,685,389 $8,315,929 $3,069,184 $61,921,469 $37.42 11 Illinois $186,635,722 $30,587,204 $47,850,352 $76,261,782 $346,208,256 $26.92 28 Indiana $64,829,390 $7,003,902 $28,350,945 $18,471,485 $122,867,573 $18.56 47 Iowa $38,335,304 $8,910,373 $13,786,769 $4,719,821 $70,448,192 $22.55 39 Kansas $37,418,874 $2,775,881 $18,860,683 $4,920,215 $69,536,639 $23.88 35 Kentucky $67,176,456 $8,620,806 $17,277,980 $11,880,117 $110,314,016 $24.93 33 Louisiana $88,213,399 $14,726,249 $28,021,343 $50,142,292 $184,207,540 $39.44 9 Maine $40,144,011 $2,815,109 $5,711,148 $2,836,574 $55,870,536 $42.03 7 Maryland $57,700,021 $7,928,159 $36,803,218 $53,332,235 $157,202,376 $26.17 30 Massachusetts $117,627,815 $33,848,364 $28,868,543 $42,063,724 $223,772,852 $32.93 14 Michigan $117,943,459 $226,823,153 $32,424,608 $30,595,325 $226,823,153 $22.86 38 Minnesota $38,040,750 $7,481,251 $23,727,752 $15,302,014 $91,371,404 $16.64 49 Mississippi $71,271,677 $5,667,838 $14,233,356 $18,181,497 $112,027,639 $37.44 10 Missouri $93,674,412 $22,119,492 $19,755,443 $28,458,827 $167,444,083 $27.52 26 Montana $40,238,229 $4,897,100 $4,251,412 $1,630,863 $55,612,013 $53.84 2 Nebraska $18,850,713 $5,225,908 $8,037,393 $4,478,023 $39,375,062 $20.77 43 Nevada $19,111,848 $2,476,542 $5,242,844 $13,836,502 $42,352,546 $14.65 50 New Hampshire $23,962,260 $2,427,152 $9,865,504 $1,559,809 $40,313,061 $30.30 21 New Jersey $73,457,881 $8,638,259 $28,294,097 $82,594,046 $193,621,768 $21.61 41 New Mexico $67,611,686 $4,646,946 $12,716,575 $5,768,301 $93,778,691 $44.98 6 New York $245,559,509 $44,406,508 $68,556,605 $327,276,875 $688,904,210 $34.80 13 North Carolina $124,621,769 $19,975,809 $28,946,906 $56,493,839 $234,452,453 $23.35 36 North Dakota $10,048,808 $2,777,143 $3,508,044 $729,683 $21,929,137 $28.97 24 Ohio $127,577,574 $39,809,459 $45,266,710 $36,890,578 $253,534,569 $21.83 40 Oklahoma $54,079,848 $10,911,063 $22,203,410 $7,868,559 $97,171,435 $24.84 34 Oregon $88,945,750 $4,788,212 $21,117,087 $12,612,129 $130,178,952 $32.31 16 Pennsylvania $118,758,294 $76,645,269 $47,555,761 $80,343,417 $328,495,128 $25.66 31 Rhode Island $26,195,684 $2,992,017 $13,932,262 $5,452,827 $48,744,388 $46.15 5 South Carolina $80,624,747 $143,316,861 $23,606,804 $32,347,408 $143,316,861 $29.27 23 South Dakota $18,816,686 $2,853,550 $5,133,618 $1,260,349 $31,397,819 $36.57 12 Tennessee $83,259,907 $21,294,809 $27,435,931 $48,713,204 $182,521,394 $27.65 25 Texas $256,200,272 $45,176,890 $62,526,290 $173,923,345 $542,034,390 $19.73 46 Utah $34,580,931 $8,123,120 $14,062,144 $6,465,997 $64,674,096 $21.59 42 Vermont $17,821,101 $1,551,207 $4,586,510 $1,424,094 $26,248,226 $41.93 8 Virginia $81,377,688 $12,721,369 $24,614,346 $44,650,589 $167,675,147 $20.00 45 Washington $129,044,530 $28,837,046 $24,129,606 $46,970,003 $233,500,587 $32.56 15 West Virginia $63,785,588 $4,941,975 $19,032,729 $2,871,432 $93,795,458 $50.86 3 Wisconsin $43,430,795 $14,932,299 $25,834,653 $11,589,246 $99,121,642 $17.17 48 Wyoming $8,792,809 $1,089,585 $1,788,047 $957,171 $13,634,115 $23.26 37 U.S. TOTAL $4,344,560,278 $1,140,028,573 $1,184,496,505 $2,176,404,811 $8,687,179,089 $27.03 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 re- flects 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] 14 TFAH • healthyamericans.org THE PREVENTION AND PUBLIC HEALTH FUND The Prevention and Public Health invest in proven strategies to improve Fund — an integral part of CDC’s health. The Fund has the support of budget and programs — enables more than 900 national, state and local communities around the country to organizations.19 Prevention and Public Health Fund Allocations (FY 2010 to FY 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 $.068 $.75 $0.75 $.50 $0.50 $.949* $.928 $.927 $.932 $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. ■ Statutory Levels Under P 110-48 (ACA) .L. ■ Sequestration *CMS Health Insurance Enrollment Support ($332 million) CDC Prevention and Public Health Fund Per Capita Allocations by State (FY 2015)* (numbers are rounded) $2.00 $6.67 $2.53 $5.13 CT: $2.26 $1.77 $2.43 NH: $2.01 $3.08 $5.12 $2.26 $1.97 MA: $5.13 $5.68 $2.50 RI: $8.11 $1.69 $1.63 $2.43 $4.16 $1.93 VT: $4.35 $3.76 $1.48 $1.16 $3.13 DC: $16.44 $1.08 $2.56 $3.68 $1.89 $1.93 $1.33 DE: $7.80 $1.23 MD: $3.01 $1.69 $2.01 $1.94 $3.47 $2.33 $2.26 NJ: $0.85 $2.19 $2.57 $2.22 $0.74 $1.96 $0.72 Over $5.01 $2.51 – $5.00 $8.49 $1.51 – $2.50 $4.85 Under $1.50 *Per capita calculations do not include grants to National Organizations TFAH • healthyamericans.org 15 PREVENTION FUND: SNAPSHOT OF SOME KEY PROGRAMS20 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 FY 2013 quit immediately. It has led to a 12 percent increase in quit to $160 million in FYs 2014, 2015 and 2016 under the attempts and prevented more than 17,000 premature deaths. Prevention Fund. l R OI: $480 spent per quitter with a $2,800 return in prema- ture death averted. Immunization Grant Program (Section 317) Hospital Promoting Breastfeeding l 324 million of funding from the Prevention Fund supports a vac- $ l$ 8 million form the Prevention Fund to support breastfeeding cine safety net for uninsured people to receive all recommended mothers and support hospitals in promoting breastfeeding. vaccinations on schedule, up from $210 million in FY 2015. l S upports registries, surveillance, outbreak response, out- reach and vaccine purchases and services. State Public Health Actions to Prevent and Control Diabetes, State and Local Public Health Actions to Prevent Obesity, Dia- Heart Disease, Obesity and Related Risk Factors and Promote betes, 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 annually to enhance key chronic P health and integrate with healthcare systems. disease prevention programs in all states and D.C. l $ 69.5 million from the Prevention Fund given to 17 states l S upports cross-cutting approaches to prevent risk factors that and four large cities. contribute to chronic diseases. State Healthcare-Associated Infections (HAIs) Prevention Program Epidemiology and Laboratory Capacity (ELC) Grants l 12 million from the Prevention Fund supports coordination $ l 40 million from the Prevention Fund supports improving a $ between public health and healthcare systems to reduce HAIs — state’s ability to detect, diagnose and contain disease outbreaks. helping to identify problem areas and improve prevention efforts. l S upports cross-cutting advancements in surveillance systems, highly expert personnel and modern scientific equipment. Million Hearts Campaign Alzheimer’s Disease Prevention Education and Outreach l$ 4 million from the Prevention Fund supports national initiative l $ 14.7 million from the Prevention Fund to expand specialized aimed at preventing 1 million heart attacks and strokes by 2017. services and support adults with Alzheimer’s disease or l P revention activities focus on ABCS (aspirin, blood pressure, related disorders. cholesterol and smoking cessation). Fall Prevention Grants Garrett Lee Smith Youth Suicide Prevention Grants l 5 million from the Prevention Fund aimed at evidence-based $ l$ 12 million from the Prevention Fund to expand program to community programs to reduce falls, the leading cause of fatal 12 additional grantees for education, training, screening, and nonfatal injuries in seniors and adults with disabilities. hotlines and support services 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 (“1421” awards) l 30 million from the Prevention Fund — $50.05 million total $ l$ 11 million from the Prevention Fund for 22 grants to prevent — supports 39 grants for culturally-tailored, evidence-based and manage heart disease, diabetes and associated risk strategies to reduce health disparities at the community level. factors in American Indian tribes and Alaskan Native villages. National Early Care and Education Collaboratives and Healthy Office of Smoking and Health Weight Taskforce l $ 126 million from the Prevention Fund to raise awareness l 4 million from the Prevention Fund supports collaboratives $ and shift attitudes and beliefs in the harmfulness of tobacco to promote children’s health by encouraging and supporting use and in the exposure of secondhand smoke, targeting healthier physical activity and nutrition practices. populations with the highest tobacco use. l S upports 1,200 programs across nine states. 16 TFAH • healthyamericans.org B. STATE INVESTMENT IN PUBLIC HEALTH State Public Health Budgets Nominal FY 2014-2015 FY 2014-2015 State Rank (Not Adjusted for Inflation) Per Capita Hawaii $224,753,616 $158.3 1 Alaska $93,214,800 $126.5 2 North Dakota $72,323,700 $97.8 3 New York $1,874,587,954 $94.9 4 Idaho $154,803,600 $94.7 5 West Virginia $134,147,149 $72.5 6 Alabama $287,264,301 $59.2 7 Wyoming $33,068,221 $56.6 8 California $2,182,461,000 $56.2 9 Rhode Island $56,145,349 $53.2 10 Massachusetts $335,705,756 $49.8 11 Arkansas $145,412,143 $49.0 12 Colorado $260,902,121 $48.7 13 New Mexico $99,350,600 $47.6 14 Tennessee $298,726,100 $45.6 15 Vermont $28,181,164 $45.0 16 Delaware $41,472,100 $44.3 17 Nebraska $81,486,579 $43.3 18 Maryland $237,627,036 $39.8 19 Oklahoma $152,538,640 $39.3 20 Iowa $120,929,906 $38.9 21 Washington $269,800,500 $38.2 22 Virginia $303,586,116 $36.5 23 MEDIAN $35.77 South Dakota $30,362,138 $35.6 24 Kentucky $148,038,883 $33.5 25 Utah $93,046,700 $31.6 26 Connecticut $111,447,778 $31.0 27 Texas $755,736,914 $28.0 28 New Jersey $240,090,000 $26.9 29 Oregon $105,442,057 $26.6 30 Illinois $325,568,512 $25.3 31 Michigan $239,432,700 $24.2 32 Montana $22,679,943 $22.2 33 Maine $28,852,183 $21.7 34 South Carolina $100,480,255 $20.8 35 Florida $402,412,648 $20.2 36 Louisiana $92,493,577 $19.9 37 Georgia $192,300,024 $19.0 38 New Hampshire $20,944,920 $15.8 39 Wisconsin $86,951,300 $15.1 40 Minnesota $79,799,506 $14.6 41 Pennsylvania $184,271,000 $14.4 42 North Carolina 141941587 $14.3 43 Ohio $159,705,848 $13.8 44 Kansas $36,082,633 $12.4 45 Indiana $81,746,582 $12.4 46 Mississippi $36,065,124 $12.0 47 Arizona $60,517,200 $9.0 48 Missouri $35,679,606 $5.9 49 Nevada $11,523,491 $4.1 50 District of Columbia $91,997,000 $139.6 N/A Source: TFAH analysis. For a detailed methodology, see Investing in America’s Health at www.healthyamericans.org TFAH • healthyamericans.org 17 Every state allocates and reports its State funding ranges dramatically, often budget in different ways. States also related to the different structures of a vary widely in the budget details they state’s public health department. Some provide. This makes comparisons departments are centralized, while others across states difficult. For this analysis, are decentralized wherein responsibilities TFAH examined state budgets and rest more on local departments than appropriations bills for the agency, at the state level. However, states and department, or division in charge of localities also place different priorities public health services for FY 2013-2014 on public health, which also accounts for and FY 2014-2015 using a definition differences in funding. The state-by-state as consistent as possible across the two comparisons included in this report’s years, based on how each state reports budget analysis do not include county data. TFAH defined “public health or city revenues that are generated to services” broadly, including most state- support local health departments, which level health funding. are also quite variable. C. LOCAL INVESTMENT IN PUBLIC HEALTH There are approximately 2,800 local NACCHO study found that median health departments in the United local public health spending was $39 per States serving a diverse assortment of capita in 2013 — up from $30 in 2005, populations ranging from fewer than while funding ranged from less than 1,000 residents in some rural jurisdictions $15 per person in Connecticut, Indiana, to around eight million people, as in the New Jersey and Massachusetts to more case of the New York City Department than $100 per person in New York and of Health.21 Local health departments Maryland.22, 23 A July 2011 study in Health (LHDs) are structured differently in Affairs found that increased spending by each state and may be centralized, local public health departments can save decentralized or have a mixed function. lives currently lost to preventable illnesses Therefore, the level of responsibility — increasing 10 percent of spending, for and services provided by LHDs varies example, will significantly decrease heart dramatically, and, correspondingly, disease deaths by more than 3 percent the way resources are determined and and infant deaths by almost 7 percent.24 allocated differs significantly. A 2014 Effects Of Local Public Health Spending On Community Mortality Rates Percent change per 10% Mortality rate increase in spending Infant deaths per 1,000 live births −6.85*** Heart disease deaths per 100,000 population −3.22** Diabetes deaths per 100,000 population −1.44** Cancer deaths per 100,000 population −1.13** Influenza deaths per 100,000 population −0.25 All-cause deaths per 100,000 population −0.29 Alzheimer’s deaths per 100,000 population 0.25 Residual deaths per 100,000 population 0.18 **p < 0.05 ***p < 0.01 Source: Health Affairs, 2011 18 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 (2014) 11.7% Texas (19.1%) (3.3%) AIDS Cumulative Cases Aged 13 and Older New York North Dakota 1,201,247 (2013 Yr End) (203,817) (210) California Alzheimer's Estimated Cases among Ages 65+ (2015) 5,426,300 Alaska (6400) (590,000) Massachusetts % Asthma Prevalence (2013) 9% Texas (7.1%) (17.6%) % Breastfeeding Exclusively at 6 Months from birth Mississippi 18.8% Vermont (29.6%) (2011) (10.1%) California Cancer Estimated New Cases (2015) 1,658,370 D.C. (2,800) (172,090) West Virginia Chlamydia Rates per 100,000 Population (2013) 456.1 D.C. (818.8) (254.5) West Virginia % Diabetes (2014) N/A Utah (7.1%) (14.1%) Drug Overdose Deaths, Aggregate Crude Rates, Ages West Virginia North Dakota 7.3 12-25, All Intents (2011-2013) (12.1) (2.2) Drug Overdose Deaths, Aggregate Rates, All Ages, All West Virginia North Dakota 13.4 Intents (2011-2013) (33.5) (2.6) Fruits per Day, % who met federal recommendations California 13.1% Tennessee (7.5%) (2013) (17.7%) California (730) Maine(73)& Oregon Human West Nile Virus Cases (as of 01/12/16) 2,060 West Virginia % Hypertension (2013) N/A Utah (24.2%) (41.0%) Colorado % Obesity (2013) N/A Arkansas (35.9%) (21.3%) Mississippi Colorado % Physical Inactivity (2013) N/A (31.6%) (16.4%) % Pneumococcal Vaccination Rates, Ages 65 and Over Alaska (60.5%) New(76.1%) Hampshire 69.3% (2014) % Seasonal Flu Vaccination Rates, Ages 65 and Over Wisconsin North Carolina 66.7% (2015) (57.2%) (76.8%) Idaho & Syphilis Rates per 100,000 Population (2014) 6.3 D.C. (17.9) Wyoming (0.7) West Virginia % Tobacco Use – Current Smokers (2014) 16.8% Utah (9.7%) (26.7%) Vermont & Tuberculosis Number of Cases (2014) 9,421 California (2,145) Wyoming (2) Vegetables, % who met federal recommendations (2013) 8.9% Mississippi (5.5%) California (13.0%)  CHILD HEALTH INDICATORS Massachusetts % Uninsured, under 18 (2013) 6.0% Alaska (11.4%) (1.5%) AIDS Cumulative Cases Under Age 13 (2014 Yr End) 9,588 New York (2,443) Wyoming (2) Nebraska % Asthma – High School Students (2013) N/A Hawaii (30.1%) (16.9%) Fruit Indicator – % High School Students (2013) N/A Alabama (24.0%) Utah (34.3%) New Hampshire High School Dropout Rate (2011-2012) 3.3% Alaska (7.0%) (1.3%) % Immunization Gap, Children Aged 19-35 Months West Virginia 28.4% Maine (15.3%) Without All Immunizations (2014) (36.6%) Infant Mortality – Per 1,000 Live Births 6.0 Mississippi (9.7) Iowa (4.1) (2013 Final Data) Mississippi % Low Birthweight Babies (2014 Final Data) 8.0% Alaska (5.9%) (11.3%) % Obesity – High School Students (2013) N/A Kentucky (18.0%) Utah (6.4%) Mississippi APRIL 2016 % Obesity, 10 to 17 Year Olds (2011) N/A Oregon (9.9%) (21.7%) Mississippi % Pre-Term Births of live births (2014 Final Data) 9.6% Oregon (7.7%) (12.9%) % Tobacco Use – 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 to ensure the Prevention and Public responsible for keeping Americans Health Fund is used to build upon and healthy and safe. Public health is expand existing efforts. The Prevention devoted to preventing disease and Fund is the nation’s largest single injury. If we kept Americans healthier, investment in prevention, using evidence- we could significantly drive down trips based and innovative partnership to the doctor’s office or emergency approaches to improve the health of room, reduce healthcare costs and Americans. Without a strong investment improve productivity. in prevention, we will never advance in the fight to prevent diseases, curb the In addition to strengthening the core obesity epidemic or reduce smoking rates. ongoing funds for public health, we need APRIL 2016 TFAH recommends that: l C ore funding for public health — at l S table, sufficient, dedicated funding the federal, state and local levels — be should be provided to support public increased; health 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 illnesses and the measles. For this to be accomplished, these Currently, inadequate and fluctuating capabilities must be fully funded, and resources, along with sequestration and funding should be tied to achieving budget caps, have left gaps in the ability and maintaining these capabilities; to quickly detect, diagnose, treat and l F unding be considered strategically contain the spread of illnesses; and — so funds are used efficiently to l A ccountability must be at the maximize effectiveness in lowering cornerstone of public health funding. disease rates and improving health; Americans deserve to know how l T he Prevention Fund should be effectively their tax dollars are used, fully allocated to support evidence- and the government’s use of funds based and innovative approaches to should be transparent and clearly improving the public health system communicated with the public. and reducing disease rates; TFAH • healthyamericans.org 21 Endnotes 1 nstitute of Medicine. The Future of the Pub- I 11 ESOLVE. “Transforming Public R 18 Health Resources and Services Adminis- lic’s Health in the 21st Century. Washington, Health: Emerging Concepts for Deci- tration. “About HRSA.” U.S. Department D.C.: National Academies Press, 2003. sion Making in a Changing Public Health of Health and Human Services. http:// World.” In Robert Wood Johnson Foundation, www.hrsa.gov/about/default.htm (ac- 2 .S. Centers for Disease Control and Pre- U 2012. http://www.rwjf.org/en/library/ cessed March 2016). vention. Public Health’s Infrastructure — A research/2012/06/transforming-public- Status Report. Atlanta, Georgia: U.S. Centers 19 Trust for America’s Health, (2015). Trust health.html (accessed 2016). for Disease Control and Prevention, 2001. for America’s Health Releases Letter De- 12 ashington State Department of Health. W tailing Strong Opposition to the Reconcil- 3 rust for America’s Health. Blueprint for T Update: A New Vision for Washington State, iation Instructions Proposed by the House a Healthier America: Modernizing the Federal September 2015. http://www.doh.wa.gov/ Energy and Commerce Committee. [Press Public Health System to Focus on Prevention Portals/1/Documents/1200/FPHS-Sep- Release]. http://healthyamericans.org/ and Preparedness. Washington, D.C.: Trust t2015update.pdf (accessed January 2016). newsroom/releases/?releaseid=331 (ac- for America’s Health, 2008. cessed April 2016). 13 esource Sharing Among Ohio’s Local R 4 Casem A and Deaton, A. Rising morbidity Health Departments. In The Center for 20 Prevention and Public Health Fund. and mortality in midlife among white non- Community Solution, 2013. http://www. Funding Distribution. In U.S. Department Hispanic Americans in the 21st century. communitysolutions.com/assets/docs/ of Health & Human Services, 2016. http:// Proceedings from the National Academy of Sciences Major_Reports/State_Budget_and_tax/ www.hhs.gov/open/prevention/ (ac- (PNAS), 112(49): 15078-15083, 2015. http:// publichealthfinal4.12.13.pdf (accessed cessed March 2016). www.pnas.org/content/112/49/15078.full. February 2016). pdf (accessed March 2016). 21 Meyer J. and Weiselberg L. County and City 14 ublic Health Futures. Considerations for a P Health Departments: The Need for Sustainable 5 rust for America’s Health. Prevention for T New Framework for Local Public Health in Funding and the Potential Effect of Healthcare a Healthier America: Investments in Prevention Ohio. Final Report. Columbus, OH: Associa- Reform on their Operations. A Report for the Yield Significant Savings, Stronger Communi- tion of Oho Health Commissioners, 2012. Robert Wood Johnson Foundation and ties, 2008. http://healthyamericans.org/ http://www.healthpolicyohio.org/public- the National Association of County & City reports/prevention08/. health-futures-considerations-for-a-new- Health Officials. Health Management As- 6 immelstein DU and Woolhandler S. H framework-for-local-public-health-in-ohio/ sociates, 2009. http://healthyamericans. Public health’s falling share of US Health (accessed February 2016). org/assets/files/HMA.pdf. Spending. American Journal of Public Health 15 ampe S, Atherly A, VanRaemdonck L, L 22 ays GP and Smith SA. Geographic Vari- M 106(1): 56-57, 2015. et al. Minimum Package of Public Health ation in Public Health Spending. Health 7 HE Fact Sheet. In Centers for Medicare & N Services: The Adoption of Core Services Serv Res 44(5 Pt 2):1796-1817, 2009. Medicaid Services. https://www.cms.gov/ in Local Public Health Agencies in Colo- 23 2013 National Profile of Local Health research-statistics-data-and-systems/statis- rado. Am J Public Health 105(Suppl 2): Departments. In National Association of tics-trends-and-reports/nationalhealthex- s252-s259, 2015 http://www.ncbi.nlm.nih. County & City Officials, 2014. http:// penddata/nhe-fact-sheet.html (accessed gov/pmc/articles/PMC4355702/ (ac- nacchoprofilestudy.org/wp-content/ January 2016). cessed February 2016). uploads/2014/02/2013_National_Pro- 8 immelstein DU and Woolhander S. H 16 ays GP and Public Health Cost Estima- M file021014.pdf (accessed April 2016). Public health’s falling share of US health tion Workgroup. Estimating the Costs of 24 Mays GP and Smith SA. Evidence Links spending. American Journal of Public Health Foundational Public Health Capabilities: A Increases in Public Health Spending to 106(1): 56-57, 2015. Recommended Methodology. Lexington, KT: Declines in Preventable Deaths. Health Af- University of Kentucky, 2014. 9 Adjusted for inflation. fairs, 30(8): 1585-1593, 2011. 17 ost of Foundational Public Health Ser- C 10 nstitute of Medicine. For the Public’s I vices. In Public Health Services and Systems Health: Investing in a Healthier Future. Research, 2015. http://www.publichealthsys- Washington, D.C.: National Academies tems.org/research/costs-foundational-pub- Press, 2012. lic-health-services (accessed February 2016). 22 TFAH • healthyamericans.org TFAH • healthyamericans.org 23 1730 M Street, NW, Suite 900 Washington, DC 20036 (t) 202-223-9870 (f) 202-223-9871