A Funding Crisis ISSUE REPORT for Public Health and Safety: 2017 STATE-BY-STATE PUBLIC HEALTH FUNDING AND KEY HEALTH FACTS APRIL 2017 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. Support for this brief was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation. TFAH BOARD OF DIRECTORS Gail C. Christopher, DN David Fleming, MD Chair of the Board, TFAH Vice President Vice President for Policy and Senior Advisor PATH WK Kellogg Foundation Octavio N. Martinez, Jr., MD, MPH, MBA, FAPA Cynthia M. Harris, PhD, DABT Executive Director Vice Chair of the Board, TFAH Hogg Foundation for Mental Health at the Director and Professor University of Texas at Austin Institute of Public Health, Florida A&M University C. Kent McGuire, PhD Theodore Spencer President and CEO Secretary of the Board, TFAH Southern Education Foundation Senior Advocate, Climate Center Eduardo Sanchez, MD, MPH Natural Resources Defense Council Chief Medical Officer for Prevention Robert T. Harris, MD American Heart Association Treasurer of the Board, TFAH Medical Director North Carolina Medicaid Support Services CSC, Inc. REPORT AUTHORS REPORT CONTRIBUTOR Laura M. Segal, MA Vinu Ilakkuvan, MPH Director of Public Affairs Health Policy and Communications Manager Trust for America’s Health Trust for America’s Health Alejandra Martín, MPH Health Policy Research Manager Trust for America’s Health 2 TFAH • healthyamericans.org A Funding INTRODUCTION Introduction The nation’s public health system has been chronically Crisis for underfunded for decades—leaving Americans unnecessarily Public Health vulnerable to preventable health problems, ranging from major disease outbreaks and bioterrorism threats to diabetes and and Safety: prescription painkiller misuse.1, 2, 3, 4 Public Health Despite the $3.36 trillion spent annually on healthcare, it has not translated states, state public health funding and key health facts — to help highlight Report into better health for the country.5 the need to invest more in improving series Today, only 3 percent of all health health and increasing the impact of spending is directed to public health, funding to achieve measurable impact. which includes federal, state and local The review provides policymakers and resources. That equates to an average of communities with an independent around $255 per person.6 By contrast, analysis; encourages transparency and total healthcare spending per person is accountability of the health system; and $10,345 per person.7 recommends strategies to modernize the nation’s public health system. The Investing in public health is one of the report includes: most common sense and effective ways to improve the health of Americans and 1. n Overview of CDC, State and Local A bring down healthcare costs. A national Public Health Funding survey of registered voters found that Chart 1: Federal Funding for States nearly three-quarters (73 percent) from CDC of Americans support increasing Chart 2: CDC’s Public Health and investments to improve the health of Prevention Funding for States communities.8  Chart 3: Federal Health Resources Insufficient funding has hampered the and Services Administration ability of the Centers for Disease Control Funding by State and Prevention (CDC), and state and Chart 4: State Public Health Funding local health departments (LHD) to keep pace with modern advancements Chart 5: Key Health Facts in technology, approaches and systems 2. ising Epidemics – and Effective R — contributing to health epidemics and Investments to Curb Crises and Cut adding avoidable healthcare costs. Costs Trust for America’s Health (TFAH) 3. ecommendations for Modernizing R conducts the Investing in America’s Public Health and Promoting a Vision Health report to examine the status for a Healthier America of federal public health funding for APRIL 2017 S EC T I ON 1 : Overview of SECTION 1: OVERVIEW Overview of CDC, State and CDC, State Local Public Health Funding and Local Flat-lined Funding for CDC: One of the world’s leading authorities Public Health for public health and the country’s front line against epidemics Funding has received relatively flat funding in recent years, budgeted at $7.17 billion in fiscal year (FY) 2016, averaging $22.26 per person. Adjusting for inflation, CDC’s budget has declined around $580 million since 2010. In the past decade, the agency’s budget has been reduced by more than 15 percent (more than $1.5 billion). In March 2017, the White House issued programs (often based on disease rates the President’s Budget Blueprint, which or other incidence formulas) and a proposes to cut 17.9 percent of funding series of competitive grants, where some for the U.S. Department of Health and states receive funding and others do not Human Services (HHS).9 While there due to insufficient funds. Because of are not sufficient details in the budget federal funding limitations, many states blueprint about the impact to specific submit competitive grants applications HHS agencies, including at the Centers that are “approved but unfunded” due for Disease Control and Prevention, it to limited funds. is clear that such a big decrease would l O f the roughly 75 percent of CDC undercut core health programs. funds that go to state and local There is nothing more valuable than communities, support ranges from a the health and vitality of the American low of $15.39 per person in Virginia to people. To achieve that, the country a high of $49.67 per person in Alaska.  must maintain a strong and stable l T welve percent of CDC’s budget ($890 public health system. Such significant million) consists of the Prevention cuts would hurt the country’s health and Public Health Fund (Prevention system — which is essential for taking Fund), a mandatory funding stream on a range of epidemics — from created by the Affordable Care Act major disease outbreaks to diabetes to (ACA) with $625 million directed prescription painkiller misuse. to state and local efforts. Among Federal dollars, through the CDC, activities supported directly by support a wide range of essential public the Prevention Fund are grants to health programs to improve health, states for infectious disease control, prevent diseases and injuries, and to resources through the Preventive prepare for major health emergencies. Health and Health Services Block Grant (Prevent Block Grant) and Approximately 75 percent of CDC’s APRIL 2017 other core public health programs. budget is distributed to states, localities and other public and private partners l P ublic Health Emergency to support services and programs. Preparedness (PHEP) Cooperative Funding for states is based on a mixture Agreement Funding, which provides of population-based formula grant support for states and localities to Katherine Welles / Shutterstock.com prepare for and respond to health Low Local Spending for Public Health: emergencies, has dropped from a Local public health expenditures Nearly half of Americans have one or more chronic disease high of $940 million in FY 2002 to average $55 per person (based on local $651 million in FY 2016. spending reported within 41 states.)13, 14 l T he entire budget for all chronic State and local funding for public disease prevention activities at CDC is health varies dramatically. One only $1.2 billion (just $4 per person per reason is the differing structures for year). Nearly half of Americans have state public health agencies and their one or more chronic disease and more activities. For example, some are than 80 percent of the annual $3 trillion centralized; others are decentralized CDC Funding Per Capita VS. Federal in healthcare spending is spent on where responsibilities rest more on Healthcare Spending Per Capita individuals with one or more chronic local departments; some are integrated condition (about $8,000 per person per with other health services or programs year for chronic disease).10, 11 and mixed functions; and some have different combinations of structures. Flat Funding for State Public Health In addition, states and localities place Since 2010: Funding has decreased in different priorities on public health, 24 states and the District of Columbia in which can account for differences in the past year, while 26 states increased or funding levels. There are approximately maintained their public health budgets 2,800 local health departments in (from FY 2014 - FY 2015 to FY 2015 - FY the United States serving a diverse 2016).12 Overall, state funding for public assortment of populations ranging from health is still below pre-recession levels. fewer than 1,000 residents in some rural Overall, adjusting for inflation, state jurisdictions to around 8 million people, public health spending has remained as in the case of the New York City relatively level since 2010 ($11.5 billion Department of Health.15 CDC Funding Federal Healthcare total, $31.62 per capita, in FY 2015-2106.) Per Capita Spending Per Capita: $22.26 $9,990 TFAH • healthyamericans.org 5 CDC — FLAT FEDERAL FUNDING FOR PUBLIC HEALTH — AROUND 75 PERCENT GOES TO STATES AND LOCALITIES CDC Program Levels — Fiscal Year 2008 to Fiscal Year 2016* $8.00 $0.19 $0.61 $0.89 $0.81 $0.83 $0.89 $6.00 $0.46 $4.00 (Billions) $6.05 $6.92 $6.75 $6.23 $6.06 $5.83 $6.02 $6.04 $6.28 $2.00 $0 2008 2009** 2010 2011 2012 2013 2014 2015 2016 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 **FY 2009 includes the 2009 Recovery Act Chronic Disease Funding — Fiscal Year 2003 to Fiscal Year 2016* $1,500 $1,125 $59 $301 $411 $244 $457 $452 $339 (Millions) $750 $790 $818 $900 $834 $825 $834 $882 $905 $774 $756 $740 $719 $747 $838 $375 $0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 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 Prevention and Public Health Fund Allocations (FY 2010 to FY 2025): Funding Under P.L. 112-96 and Under H.R. 6 (21st Century Cures) vs. Funding Established by P.L. 110-48 (ACA) $2.00 $2.00 $2.00 $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 $0.051 $0.072 $0.073 $0.068 $0.75 $0.75 $0.50 $0.50 $0.949* $0.928 $0.927 $0.932 $1.00 $0.90 $0.90 $1.00 $1.00 $1.50 $1.00 $1.70 $0.25 $0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 ■ Under P.L. 112-96 (Current Level) ■ Statutory Levels Under P.L. 110-48 (ACA) ■ H.R. 6 (21st Century Cures) ■ Sequestration ■ CMS Health Insurance Enrollment Support ($332 million) CDC Prevention and Public Health Fund Per Capita Allocations Note: Federal CDC funding to states is by State (FY 2015)* based on a mixture of population-based (numbers are rounded) formula grant programs (often based on $2.00 disease rates or other incidence formulas) $6.67 $2.53 $5.13 CT: $2.26 and a series of competitive grants where $1.77 $2.43 NH: $2.01 $3.08 $5.12 $2.26 $1.97 MA: $5.13 some states receive funding and others $5.68 $2.50 $1.69 RI: $8.11 do not due to insufficient funds. Because $4.16 $1.63 $2.43 $1.93 VT: $4.35 $1.48 of federal funding limitations, many states $3.76 $1.16 $1.08 $2.56 $3.13 DC: $16.44 $3.68 $1.89 submit competitive grants applications $1.93 $1.33 DE: $7.80 $1.23 MD: $3.01 that are “approved but unfunded” due to $1.69 $2.01 $1.94 $3.47 $2.33 $2.26 NJ: $0.85 limited funds. $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 7 8 TFAH • healthyamericans.org LOCAL HEALTH DEPARTMENT BUDGETS Median and Mean Annual per Capita Expenditures and Revenues by LHD Characteristics Expenditures Revenue Median Mean Median Mean ALL LHDs $39 $55 $41 $54 Size of Population Served <25,000 $49 $68 $51 $65 25,000 – 49,999 $32 $46 $37 $50 50,000 – 99,999 $30 $48 $40 $48 100,000 – 249,999 $33 $40 $33 $40 250,000– 499,999 $32 $46 $31 $44 500,000 –999,999 $37 $48 $36 $50 1,000,000+ $31 $44 $33 $43 Type of Governance State $35 $40 $38 $45 Local $38 $53 $38 $51 Shared $58 $78 $69 $86 n(expenditure)—1,286 n(revenue)—1,166 Source: National Association of County and City Health Officials (NACCHO) 2016 National Profile of Local Health Departments TFAH • healthyamericans.org 9 HIGHLIGHT PUBLIC HEALTH Prevention and Public Health Fund: 12 Percent of CDC’s PROGRAMS IN ACTION Budget, $625 Million Annually to States and Local Areas Twelve percent of CDC’s budget is supported by the Prevention and Public Health Fund ($890 million annually). $625 million of these funds go directly to states to support public health activities. The Prevention Fund supports services and l P roviding financial support directly to programs that allow health to be improved states and communities, and giving in communities, schools, workplaces and them the flexibility to address their homes by making healthy choices easier most pressing health challenges and for millions of Americans, including by: invest in programs that are proven effective; and l S upporting prevention efforts targeted at reducing tobacco use, increasing l E nsuring oversight and evaluation physical activity, improving nutrition, of every Fund-sponsored program, expanding mental health and injury and implementing strict performance prevention programs and improving measures to ensure accountability prevention activities; before federal dollars are spent. KEY PROGRAMS Preventive Health and Health Services Block Grant The Preventive Health and Health Services have the flexibility to use funds to respond supports capacity building and core service Block Grant provides all 50 states, the rapidly to emerging health issues and to development in various areas, including District of Columbia, two American Indian fill funding gaps in programs that deal with chronic disease prevention, health promotion, tribes, and eight U.S. territories with leading causes of death and disability. communicable disease prevention, flexible funding to address their unique environmental health, injury prevention and The Prevent Block Grant received $160 public health issues at the state and emergency medical services. Prevention million in Fiscal Years 2014, 2015 and 2016 community level in innovative and locally funds can augment limited categorical from the Prevention Fund. The program defined ways. 16 States and other awardees program funds at the state or local level. Top 10 Funded Health Topic Areas and Sexual Violence Fiscal Year 2016 $136,936,530 ■ Public Health Infrastructure $36,112,339 18% ■ Educational and Community-Based Programs $26,287,966 ■ Nutrition and Weight Status $10,470,533 26% ■ Injury and Violence Prevention $9,703,291 ■ Heart Disease and Stroke $6,157,936 6% ■ Immunization and Infectious Diseases $4,257,397 3% ■ Emergency Medical Services $4,026,311 3% ■ Oral Health $3,903,731 ■ Diabetes $3,841,819 3% 3% ■ Sexual Violence (Rape Prevention) $8,066,936 19% 4% ■ Other Health Topic Areas Combined $24,108,271 TOTAL $136,936,530 7% 8% Administrative costs (up to 10%); Direct Assistance not included 10 TFAH • healthyamericans.org Tips from Former Smokers Campaign Million Hearts Campaign l T his evidence-based tobacco education campaign has helped 1.8 l $ 4 million from the Prevention Fund supports national initiative million Americans attempt to quit and 500,000 to successfully aimed at preventing 1 million heart attacks and strokes by 2017. quit long term. It has led to a 12 percent increase in quit l P revention activities focus on Aspirin use, Blood pressure, attempts and prevented more than 17,000 premature deaths. Cholesterol management and Smoking cessation (ABCS). l he return on investment is significant: $480 spent per quitter T resulting in a $2,800 return in premature death averted. Alzheimer’s Disease Prevention Education and Outreach l $ 14.7 million from the Prevention Fund to expand specialized Immunization Grant Program (Section 317) services and support adults with Alzheimer’s disease or l $ 324 million from the Prevention Fund supports a vaccine related disorders. safety net for uninsured people to receive all recommended vaccinations on schedule, up from $210 million in FY 2015. Fall Prevention Grants l $ 5 million from the Prevention Fund aimed at evidence-based l T he program supports registries, surveillance, outbreak response, community programs to reduce falls, the leading cause of fatal outreach and vaccine purchases and services. and nonfatal injuries in seniors and adults with disabilities. Hospital Promoting Breastfeeding l A wards to 14 states and localities. l $ 8 million from the Prevention Fund supports breastfeeding mothers by providing hospitals with breastfeeding promotion strategies. Garrett Lee Smith Youth Suicide Prevention Grants l $ 12 million from the Prevention Fund to expand program to 12 State Public Health Actions to Prevent and Control Diabetes, additional grantees for education, training, screening, hotlines Heart Disease, Obesity and Related Risk Factors, and Promote and support services to prevent youth suicides. School Health (“1305” Awards) l $ 33 million from the Prevention Fund supports 1305 grants to Racial and Ethnic Approaches to Community Health (REACH) enhance key chronic disease prevention programs in all states l $ 30 million from the Prevention Fund, out of $50.95 million in and the District of Columbia. total, supports 39 grants for culturally-tailored, evidence-based strategies to reduce health disparities at the community level. l S upports multi-sector approaches to prevent risk factors that contribute to chronic diseases. Good Health and Wellness in Indian Country (“1421” Awards) l $ 11 million from the Prevention Fund supports 22 grants to State and Local Public Health Actions to Prevent Obesity, prevent and manage heart disease, diabetes and associated risk Diabetes, and Heart Disease and Stroke (“1422” Awards) factors in American Indian tribes and Alaskan Native villages. l F our-year project to create community strategies to promote health and integrate with healthcare systems. National Early Care and Education Collaboratives and Healthy l $ 69.5 million from the Prevention Fund supports efforts in 17 Weight Taskforce states and four large cities. l $ 4 million from the Prevention Fund supports collaboratives to promote children’s health by encouraging and supporting State Healthcare-Associated Infections (HAIs) Prevention Program healthier physical activity and nutrition practices. l $ 12 million from the Prevention Fund supports coordination l S upports more than 1,200 programs across nine states. between public health and healthcare systems to reduce HAIs, helping to identify problem areas and improve prevention efforts. Office of Smoking and Health l $ 126 million from the Prevention Fund raises awareness Epidemiology and Laboratory Capacity (ELC) Grants and shift attitudes and beliefs regarding the harmfulness of l 40 million from the Prevention Fund supports improving a state’s $ tobacco use and the exposure of secondhand smoke, targeting ability to detect, diagnose and contain disease outbreaks. populations with the highest tobacco use. l S upports cross-cutting advancements in surveillance systems, highly- Source: U.S. Department of Health and Human Services trained and expert personnel, and modern scientific equipment. TFAH • healthyamericans.org 11 CDC FUNDING BY STATE 2016 Agency for Toxic Birth Defects, CDC-Wide Chronic Health Emerging HIV/AIDS, Substances Developmental Activities Disease Ebola HealthReform – Toxic and Zoonotic Environmental Viral Hepatitis, State and Disease Disabilities, and Program Prevention Response and Reform – Substances & Infectious Health STI and TB Registry Disability and Support (*see and Health Preparedness Obesity Environmental Diseases Prevention (ATSDR) Health note in source) Promotion Public Health Alabama $2,030,581 $2,665,469 $13,201,302 $1,616,259 $1,307,752 $9,324,405 Alaska $357,639 $668,508 $736,389 $11,695,783 $234,638 $1,496,888 $2,108,783 Arizona $298,884 $978,002 $1,852,024 $11,831,890 $2,735,926 $1,895,385 $596,181 $1,714,950 $8,565,715 Arkansas $374,054 $2,075,741 $1,571,823 $10,077,719 $1,796,222 $1,842,167 $3,644,599 California $789,039 $1,586,105 $10,708,971 $56,205,942 $7,629,613 $10,955,277 $4,104,594 $102,518,293 Colorado $386,764 $3,471,348 $2,117,130 $10,661,705 $833,077 $6,613,386 $1,528,130 $11,365,234 Connecticut $498,307 $170,000 $2,250,001 $6,967,695 $1,161,582 $4,799,046 $1,752,847 $7,330,682 Delaware $98,826 $475,275 $5,468,895 $858,259 $977,924 $102,113 $2,463,102 D.C. $350,000 $5,614,041 $2,632,036 $26,390,142 $6,723,445 $3,512,911 $3,100,863 $23,182,486 Florida $443,878 $742,869 $4,614,014 $23,886,512 $8,575,025 $3,416,785 $2,095,264 $55,081,623 Georgia $215,805 $5,713,196 $7,279,566 $40,204,399 $4,381,731 $9,799,663 $1,743,587 $28,554,091 Hawaii $244,827 $1,218,233 $8,404,834 $2,624,258 $4,743,282 $519,221 $2,544,971 Idaho $201,477 $148,337 $774,002 $6,801,751 $452,506 $767,529 $1,452,173 Illinois $1,500,000 $2,209,258 $3,602,710 $32,004,578 $2,802,939 $9,573,038 $1,701,319 $30,610,823 Indiana $168,721 $2,530,701 $8,128,801 $1,608,477 $2,581,601 $844,891 $6,166,322 Iowa $2,114,198 $1,702,233 $8,271,065 $1,388,921 $2,893,663 $685,505 $2,174,052 Kansas $314,995 $1,455,612 $12,695,570 $1,015,162 $1,838,060 $639,753 $2,296,536 Kentucky $523,719 $2,251,515 $11,000,347 $1,456,908 $2,039,682 $857,006 $3,661,413 Louisiana $678,385 $5,747,469 $10,540,538 $5,336,595 $1,563,653 $1,619,452 $14,924,304 Maine $154,734 $1,567,859 $7,447,354 $1,175,051 $1,465,273 $1,362,286 $1,347,445 Maryland $4,287,554 $3,684,955 $20,574,168 $5,830,704 $14,668,051 $2,410,824 $26,389,522 Massachusetts $402,138 $1,876,302 $4,510,887 $19,714,051 $1,776,141 $10,237,861 $2,965,995 $1,477,519 $16,495,311 Michigan $440,581 $685,000 $6,661,702 $25,497,684 $1,284,328 $3,412,528 $2,028,194 $14,691,321 Minnesota $451,913 $1,566,635 $3,932,953 $19,476,394 $1,529,660 $12,975,747 $2,354,141 $6,587,278 Mississippi $102,345 $2,261,069 $12,118,287 $1,783,216 $992,958 $659,703 $7,127,534 Missouri $331,895 $1,890,371 $4,029,422 $8,901,535 $1,607,490 $6,162,490 $1,852,597 $9,667,670 Montana $453,713 $1,032,403 $8,088,171 $399,728 $1,762,992 $475,407 $2,499,999 $1,368,070 Nebraska $156,374 $2,599,880 $11,714,444 $1,631,701 $2,141,230 $9,405 $1,810,005 Nevada $628,710 $608,558 $9,069,545 $1,181,125 $1,605,945 $385,664 $4,071,214 New Hampshire $354,586 $554,435 $2,231,276 $6,982,397 $1,062,527 $2,037,574 $2,999,774 $1,231,029 New Jersey $578,728 $787,500 $4,658,343 $7,250,257 $2,887,750 $1,896,652 $1,988,534 $25,213,699 New Mexico $1,310,000 $59,678 $2,191,126 $8,525,057 $1,674,650 $3,577,871 $1,956,351 $2,947,168 New York $676,166 $5,606,246 $11,798,670 $42,596,954 $9,092,161 $13,529,341 $5,933,701 $93,927,608 North Carolina $320,128 $3,442,476 $4,436,442 $20,159,239 $1,861,426 $7,598,186 $1,000,891 $15,719,083 North Dakota $155,703 $571,353 $5,141,377 $545,104 $714,572 $1,291,563 Ohio $524,981 $7,013,936 $18,298,289 $1,883,374 $5,195,204 $1,134,429 $12,747,992 Oklahoma $354,722 $1,449,458 $10,690,200 $924,886 $1,014,635 $271,204 $3,972,076 Oregon $436,965 $836,766 $1,110,980 $14,509,480 $820,850 $4,949,033 $2,084,510 $5,226,128 Pennsylvania $455,685 $310,523 $7,390,984 $17,811,477 $3,756,750 $8,209,678 $1,836,647 $25,537,938 Rhode Island $328,289 $736,138 $10,959,945 $1,288,135 $1,821,653 $1,285,310 $2,158,672 South Carolina $3,931,398 $2,081,996 $17,029,820 $1,587,477 $2,919,925 $664,833 $9,226,761 South Dakota $135,943 $535,387 $8,444,262 $156,685 $1,455,557 $1,340,993 Tennessee $277,550 $839,911 $2,689,306 $9,074,764 $783,938 $10,242,794 $564,182 $13,155,820 Texas $392,173 $1,392,225 $6,288,485 $18,774,104 $4,593,416 $5,789,041 $549,412 $53,191,687 Utah $222,845 $1,439,250 $1,499,882 $13,986,387 $194,356 $3,352,789 $2,336,370 $2,135,972 Vermont $307,354 $423,511 $4,692,657 $304,573 $1,310,287 $1,999,760 $1,618,741 Virginia $256,292 $135,616 $3,341,888 $15,223,598 $984,354 $4,193,123 $883,432 $15,364,137 Washington $533,600 $398,583 $1,549,477 $22,441,548 $110,916 $6,918,914 $1,239,987 $13,682,922 West Virginia $1,581,010 $5,917,590 $640,405 $1,642,689 $327,790 $1,741,891 Wisconsin $445,246 $2,106,763 $3,031,233 $11,272,661 $548,436 $6,286,563 $2,325,176 $4,394,530 Wyoming $141,948 $551,647 $3,190,049 $85,955 $1,368,231 $1,357,531 Grand Total $13,302,338 $65,143,705 $154,237,389 $750,013,213 $107,218,811 $224,067,079 $67,777,235 $3,192,469 $2,499,999 $714,708,918 Note: *CDC-Wide Activities and Program Support does not include Ebola funding, Ebola funding is reported separately. **D.C. was not included in the per capita rankings because it receives different funding levels than the 50 states. ***Grand Totals includes funding only for U.S. States and the District of Columbia, no territories (e.g. Guam, Puerto Rico) or large cities (e.g. Los Angles, New York). 12 TFAH • healthyamericans.org CDC FUNDING BY STATE 2016 National Total CDC Total CDC Immunization Public Health World Trade Injury Institute for Public Health Total CDC Funding for Funding and Scientific Vaccines for Center Health State Prevention and Occupational Preparedness Funding for State, Per for State, Respiratory Services Children Programs Control Safety and and Response State, FY 2016 Capita, FY Per Capita, Diseases (PHSS) (WTC) Health 2016 Ranking Alabama $4,826,708 $1,119,613 $1,899,231 $8,564,969 $553,278 $57,922,610 $105,032,177 $21.60 26 Alaska $1,972,845 $1,721,672 $100,966 $4,214,898 $425,575 $11,115,801 $36,850,385 $49.67 1 Arizona $6,714,274 $2,211,709 $555,971 $11,124,291 $761,029 $94,215,323 $146,051,554 $21.07 33 Arkansas $3,472,160 $676,361 $6,249,569 $569,439 $39,270,497 $71,620,351 $23.97 19 California $35,902,478 $9,482,544 $8,732,607 $57,464,183 $1,678,523 $461,906,482 $769,664,651 $19.61 38 Colorado $6,333,210 $4,964,093 $6,213,382 $9,247,378 $691,227 $52,628,464 $117,054,528 $21.13 32 Connecticut $4,847,343 $2,205,270 $1,150,881 $7,650,851 $257,326 $31,510,771 $72,552,602 $20.29 35 Delaware $1,555,032 $1,928,528 $4,243,150 $28,692 $10,505,225 $28,705,021 $30.15 9 D.C. $7,610,520 $5,418,875 $214,468 $12,231,204 $11,905,252 $11,346,189 $120,232,432 $176.51 N/A* Florida $12,883,324 $2,462,442 $3,349,279 $27,623,857 $100,000 $248,150,354 $393,425,226 $19.09 40 Georgia $17,659,133 $3,135,137 $1,660,790 $15,777,404 $5,557,132 $131,572,335 $273,253,969 $26.50 16 Hawaii $1,969,106 $955,146 $5,689,134 $1,178,444 $15,281,553 $45,373,009 $31.76 8 Idaho $2,094,451 $1,257,087 $274,960 $4,882,297 $38,932 $22,203,778 $41,349,280 $24.57 18 Illinois $12,766,903 $3,902,933 $3,191,487 $25,518,819 $466,867 $84,758,427 $214,610,101 $16.76 47 Indiana $5,680,169 $3,248,892 $10,974,657 $202,658 $71,386,140 $113,522,030 $17.11 45 Iowa $4,478,295 $1,606,453 $4,587,799 $6,531,337 $236,501 $31,343,809 $68,013,831 $21.70 25 Kansas $3,034,522 $1,675,645 $6,793,355 $496,124 $26,641,522 $58,896,856 $20.26 36 Kentucky $4,872,505 $5,278,321 $3,134,937 $7,878,787 $43,091 $50,940,348 $93,938,579 $21.17 31 Louisiana $3,281,892 $1,399,877 $390,918 $8,768,444 $939,838 $73,991,845 $129,183,210 $27.59 13 Maine $2,709,484 $1,926,256 $4,693,663 $67,961 $13,333,239 $37,250,605 $27.98 12 Maryland $12,602,785 $4,279,726 $8,153,990 $11,846,387 $9,000,502 $68,349,939 $192,079,107 $31.93 6 Massachusetts $6,127,400 $3,861,169 $9,678,835 $13,332,037 $562,439 $66,559,377 $159,577,462 $23.43 20 Michigan $11,015,360 $5,802,180 $3,275,084 $16,106,712 $953,626 $94,834,675 $186,688,975 $18.80 43 Minnesota $7,869,517 $1,814,325 $3,770,988 $11,145,506 $338,180 $45,113,002 $118,926,239 $21.54 28 Mississippi $3,083,727 $379,230 $130,000 $6,386,134 $241,129 $40,874,980 $76,140,312 $25.48 17 Missouri $5,424,540 $1,184,535 $322,573 $10,399,993 $152,821 $63,717,425 $115,645,357 $18.98 41 Montana $1,617,796 $526,434 $209,231 $4,203,760 $275,933 $10,202,481 $33,116,118 $31.77 7 Nebraska $2,279,477 $1,455,633 $1,627,855 $5,250,581 $174,084 $19,953,043 $50,803,712 $26.64 15 Nevada $3,093,480 $1,109,414 $6,497,094 $256,598 $34,863,048 $63,370,395 $21.55 27 New Hampshire $2,007,160 $1,881,060 $145,000 $4,876,732 $170,378 $10,210,855 $36,744,783 $27.53 14 New Jersey $8,247,597 $2,008,701 $468,725 $14,691,760 $3,960 $77,384,436 $347,074 $148,413,716 $16.59 48 New Mexico $4,234,426 $2,614,766 $627,143 $7,524,273 $197,944 $30,519,156 $67,959,609 $32.66 5 New York $24,029,943 $7,548,414 $6,044,631 $35,551,617 $2,377,480 $109,807,204 $14,716,536 $383,236,672 $19.41 39 North Carolina $8,341,463 $5,301,691 $1,568,421 $13,668,090 $291,970 $107,148,526 $190,858,032 $18.81 42 North Dakota $2,354,254 $201,959 $4,114,287 $252,269 $7,307,066 $22,649,507 $29.88 10 Ohio $10,409,754 $5,445,198 $2,463,294 $16,874,516 $913,517 $125,024,643 $207,929,127 $17.90 44 Oklahoma $4,326,380 $2,101,432 $537,318 $7,502,035 $940,426 $56,861,854 $90,946,626 $23.18 21 Oregon $6,193,777 $3,519,137 $1,921,986 $7,748,697 $618,070 $37,730,570 $87,706,949 $21.43 29 Pennsylvania $13,881,361 $6,683,165 $2,608,772 $17,545,533 $1,312,776 $90,508,773 $197,850,062 $15.48 49 Rhode Island $1,959,195 $3,700,638 $503,698 $4,443,649 $551,344 $12,085,685 $41,822,351 $39.59 3 South Carolina $4,684,561 $2,152,359 $9,968,837 $354,211 $57,606,504 $112,208,682 $22.62 23 South Dakota $1,429,854 $428,827 $3,909,653 $383,076 $11,183,773 $29,404,010 $33.98 4 Tennessee $7,461,696 $2,820,178 $491,553 $10,489,560 $464,933 $79,477,917 $138,834,102 $20.87 34 Texas $28,277,339 $2,833,369 $4,755,521 $34,658,505 $388,287 $431,032,032 $592,915,596 $21.28 30 Utah $3,230,997 $3,508,741 $1,797,486 $6,604,603 $815,827 $26,583,914 $67,709,419 $22.19 24 Vermont $1,606,101 $1,138,340 $6,200 $4,106,616 $516,321 $7,934,289 $25,964,750 $41.57 2 Virginia $7,544,905 $3,750,310 $600,789 $14,697,194 $1,567,925 $60,952,334 $129,495,897 $15.39 50 Washington $8,636,775 $3,479,250 $5,724,859 $11,418,815 $886,807 $69,181,978 $146,204,431 $20.06 37 West Virginia $1,819,693 $2,889,661 $812,372 $5,616,070 $48,711 $19,003,747 $42,041,629 $22.96 22 Wisconsin $8,131,180 $3,584,626 $2,211,611 $11,841,152 $128,813 $41,280,162 $97,588,152 $16.89 46 Wyoming $1,276,378 $192,919 $3,985,702 $19,756 $5,213,750 $17,383,866 $29.69 11 U.S. TOTAL $357,863,225 $144,774,241 $95,915,611 $583,128,347 $51,358,002 $3,458,531,850 $15,063,610 $6,808,796,041 $21.07 N/A* Source: CDC. For a detailed list of references, see Investing in America’s Health at www.healthyamericans.org Note: Totals include CDC funds for organizations within the state. TFAH • healthyamericans.org 13 FY 2016 HRSA Grants to States by Selected Key Program Areas Total HRSA Funding Total HRSA Funding Total HRSA Primary Health Care Health Professions Maternal & Child State HIV/AIDS Funding for State (All for State, Per Capita Funding for State, Funding Funding Health Funding Programs) (All Programs) Per Capita Ranking Alabama $79,429,070 $23,481,273 $22,384,598 $22,705,618 $151,176,263 $31.09 18 Alaska $68,653,848 $2,980,560 $4,492,087 $2,282,999 $80,677,571 $108.75 1 Arizona $85,868,562 $9,092,915 $22,968,492 $10,467,620 $133,668,450 $19.29 46 Arkansas $50,216,840 $11,502,020 $16,659,186 $9,383,540 $91,998,904 $30.79 19 California $637,060,904 $86,798,596 $79,269,005 $294,157,049 $1,104,642,423 $28.14 26 Colorado $105,781,067 $16,150,468 $21,099,572 $21,006,149 $168,634,269 $30.44 20 Connecticut $60,666,386 $13,413,423 $16,920,409 $15,474,819 $107,139,527 $29.96 22 Delaware $14,120,176 $5,217,801 $7,481,579 $3,247,492 $30,239,048 $31.76 16 D.C. $27,104,217 $17,979,522 $20,278,719 $75,765,176 $142,542,230 N/A* N/A* Florida $233,236,939 $26,180,317 $38,418,328 $199,829,233 $499,361,893 $24.23 34 Georgia $113,003,230 $19,919,906 $29,739,769 $107,807,440 $274,282,701 $26.60 29 Hawaii $44,560,137 $10,012,232 $8,089,584 $2,963,251 $66,901,441 $46.83 8 Idaho $45,075,996 $2,817,603 $6,763,988 $3,974,353 $60,209,411 $35.77 12 Illinois $197,811,450 $33,833,043 $42,712,093 $76,344,000 $356,026,713 $27.81 28 Indiana $73,005,921 $9,301,848 $26,602,910 $18,375,372 $131,139,429 $19.77 45 Iowa $38,781,892 $6,467,718 $14,792,111 $12,105,116 $76,751,957 $24.48 32 Kansas $42,221,957 $2,146,388 $13,431,458 $4,908,955 $68,224,897 $23.47 36 Kentucky $71,979,233 $8,040,651 $19,629,297 $11,643,749 $117,422,258 $26.46 30 Louisiana $94,675,058 $13,819,361 $27,053,799 $42,117,500 $181,636,978 $38.80 10 Maine $43,672,695 $3,101,800 $10,897,107 $2,843,033 $64,691,116 $48.59 5 Maryland $62,804,115 $6,429,785 $34,368,090 $33,182,554 $138,637,834 $23.04 39 Massachusetts $131,220,239 $39,108,359 $36,180,759 $43,483,243 $251,815,014 $36.97 11 Michigan $126,344,181 $32,291,000 $37,408,154 $31,199,772 $231,713,417 $23.34 37 Minnesota $39,366,659 $8,742,716 $22,030,657 $14,924,621 $91,664,188 $16.61 49 Mississippi $72,923,396 $5,425,153 $15,440,007 $25,406,273 $122,805,532 $41.09 9 Missouri $108,158,466 $22,143,281 $21,486,623 $28,493,142 $184,814,115 $30.33 21 Montana $40,905,313 $4,682,978 $7,367,312 $3,065,299 $60,095,669 $57.64 2 Nebraska $22,498,119 $6,576,683 $7,952,252 $6,759,691 $46,500,803 $24.38 33 Nevada $20,144,642 $2,262,387 $5,516,351 $16,299,048 $45,789,233 $15.57 50 New Hampshire $24,702,300 $4,116,440 $6,706,537 $2,006,344 $39,376,453 $29.50 24 New Jersey $83,741,861 $7,394,201 $27,668,049 $74,353,571 $193,803,186 $21.67 41 New Mexico $75,956,005 $3,738,974 $11,698,385 $5,725,370 $100,390,634 $48.24 7 New York $262,488,978 $37,852,750 $60,746,208 $327,559,780 $691,627,532 $35.03 14 North Carolina $124,287,318 $20,343,490 $27,299,625 $57,686,441 $233,486,867 $23.01 40 North Dakota $9,661,999 $4,120,203 $3,423,974 $696,733 $21,591,992 $28.49 25 Ohio $138,696,661 $41,877,589 $38,808,503 $26,038,093 $248,861,423 $21.43 43 Oklahoma $57,279,977 $4,615,966 $18,344,874 $2,148,998 $84,368,590 $21.50 42 Oregon $91,440,272 $4,425,953 $18,120,792 $12,377,583 $128,598,442 $31.42 17 Pennsylvania $120,827,850 $70,102,261 $46,759,953 $80,539,162 $322,821,371 $25.25 31 Rhode Island $27,893,350 $3,445,892 $11,579,522 $8,146,014 $51,236,778 $48.50 6 South Carolina $84,374,726 $5,662,499 $23,284,705 $32,076,241 $147,618,443 $29.76 23 South Dakota $17,955,356 $2,701,874 $5,119,701 $1,261,434 $30,583,859 $35.34 13 Tennessee $84,763,179 $22,062,792 $26,393,766 $51,045,624 $186,856,249 $28.09 27 Texas $251,837,532 $50,007,671 $59,893,994 $170,619,344 $537,158,782 $19.28 47 Utah $39,274,445 $8,907,072 $15,923,294 $7,228,476 $72,768,681 $23.85 35 Vermont $26,115,173 $1,435,943 $4,351,459 $1,444,947 $34,194,333 $54.75 3 Virginia $89,005,214 $14,280,537 $22,699,609 $46,662,277 $177,385,292 $21.09 44 Washington $131,401,065 $25,628,857 $22,692,187 $48,148,469 $231,935,810 $31.82 15 West Virginia $69,104,620 $4,513,704 $14,119,763 $1,673,112 $92,308,177 $50.41 4 Wisconsin $46,684,774 $17,559,569 $23,674,618 $13,271,554 $104,275,989 $18.04 48 Wyoming $8,797,905 $1,122,317 $1,656,050 $955,375 $13,540,024 $23.13 38 U.S. TOTAL $4,617,581,268 $805,836,341 $1,128,399,864 $2,111,881,050 $8,825,992,192 $27.31 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 U.S. total reflects HRSA grants to all 50 states and the District of Columbia. Source: HRSA. For a detailed list of references, see Investing in America’s Health at www.healthyamericans.org Note: HRSA distributes approximately 90 percent of its funding in grants to states and territories, public and private healthcare providers, health pro- fessions training programs and other organizations.17 HRSA’s funding is not distributed on a strictly per capita basis. The bulk of HRSA funds are in its two largest programs, the community and migrant health centers and the Ryan White Act HIV programs, and these dollars are awarded on a competitive basis and/or based on disease burden. 14 TFAH • healthyamericans.org CDC’s Prevention and State Public Health Budgets Public Health Fund State Nominal FY 2015– 2016 State PPHF, All Grants State Alabama^ $291,295,624 Awarded by CDC, FY 2016 Alabama $8,973,423 Alaska– $88,717,700 Alaska $4,462,597 Arizona^ $61,750,600 Arizona $9,368,015 Arkansas^ $159,503,870 Arkansas $5,919,989 California^ $2,237,649,000 California $61,553,706 Colorado– $243,557,860 Colorado $8,934,369 Connecticut– $108,381,858 Connecticut $7,345,772 Delaware– $41,302,100 Delaware $2,492,564 D.C> $92,025,000 D.C. $10,306,616 Florida– $375,568,783 Florida $20,372,850 Georgia^ $200,496,288 Georgia $20,084,351 Hawaii^ $260,921,312 Hawaii $8,005,176 Idaho– $149,693,200 Idaho $4,485,717 Illinois– $278,410,100 Illinois $18,616,970 Indiana*^ $88,281,103 Indiana $8,276,290 Iowa– $254,967,727 Iowa $7,126,042 Kansas* $35,323,658 Kansas $9,065,813 Kentucky– $139,938,945 Kentucky $8,137,514 Louisiana* $91,089,760 Louisiana $9,022,206 Maine* $28,831,397 Maine $5,517,600 Maryland– $220,581,000 Source: TFAH analysis. For a detailed Maryland $16,975,209 Massachusetts^ $347,795,292 methodology, see Ready or Not? Protecting the Massachusetts $17,622,501 Michigan^ $169,511,700 Public’s Health from Diseases, Disasters and Michigan $22,147,815 Minnesota– $306,656,000 Bioterrorism at www.healthyamericans.org. Minnesota $16,151,974 Mississippi^ $37,938,160 States vary significantly in how they structure Mississippi $6,255,371 Missouri– $35,786,884 public health agencies, programs and services Montana^ $25,237,849 — so it makes direct comparisons across states Missouri $10,770,773 Nebraska*^ $91,908,003 difficult. For instance, states may have more Montana $4,966,229 Nevada*^ $12,227,147 centralized or decentralized public structures, Nebraska $9,591,525 or some public health agencies may include Nevada $3,834,916 New Hampshire– $16,883,416 environmental health, behavioral health or some New Hampshire $4,993,404 New Jersey^ $240,090,000 direct services, depending on the structure of New Jersey $12,111,673 New Mexico– $96,537,600 the state agencies. The budgets may include New Mexico $8,651,427 New York– $1,766,294,100 unrealized collection authority and may or may New York $41,517,446 North Carolina* $141,377,220 not include revenue from local sources. State North Carolina $17,183,464 North Dakota^ $36,161,850 budget numbers may include fee collection North Dakota $2,995,110 Ohio^ $165,551,980 authority that may not be realized and is not Oklahoma– $166,416,000 revenue for the state. And, state budget Ohio $22,990,225 Oregon^ $113,306,169 numbers may include grants to support local Oklahoma $9,317,151 Pennsylvania^ $188,429,000 health agencies but do not reflect revenue from Oregon $9,292,480 local government (e.g., city or county taxes). Pennsylvania $22,398,271 Rhode Island^ $56,976,434 Rhode Island $8,047,792 South Carolina^ $119,916,820 Notes: North Dakota and Virginia report South Dakota^ $30,858,176 biennium budgets, and for this analysis the South Carolina $11,315,305 Tennessee^ $307,404,600 funding was divided in two to reflect one-year South Dakota $3,746,565 Texas– $745,419,816 spending levels. Tennessee $13,507,582 Texas $29,442,970 Utah– $93,679,000 ^ States that increased or maintained budgets Utah $9,879,302 Vermont^ $32,608,988 from FY 2014-2015 to FY 2015-2016. Vermont $2,927,513 Virginia^ $151,764,308 – States that decreased budgets from FY Virginia $15,420,904 Washington^ $297,057,572 2014-2015 to FY 2015-2016. For states with Washington $14,012,178 West Virginia* $119,085,170 biennium budgets, reflects changes to the two- West Virginia $4,533,864 Wisconsin– $87,738,900 year cycle. Wisconsin $12,824,029 Wyoming^ $33,068,221 * States that did not respond to requests to Wyoming $2,204,994 U.S. $11,481,973,260 review their state budget information. The most Median State Spending recent publicly available data is used for states Source: CDC. For a detailed list of references, $31.62 Per Capita that did not provide additional information. see Investing in America’s Health at www.healthyamericans.org TFAH • healthyamericans.org 15 TFAH’s Blueprint for a Healthier America improve nutrition and reduce tobacco 2016: Policy Priorities for the Next use could save the country more than Administration reviewed how investing $16 billion annually – a $5.60:1 return.23 in proven public health strategies l C onnecting health and social services can improve health and yield positive to cut billions in costs.  Health and returns.  For instance:   social service coordinating systems l I nvesting $1 in substance use that address gaps between medical prevention to realize as much as $34 care and effective social service in return.  Deaths from prescription programs – by connecting patients painkiller use have more than in need with programs ranging from quadrupled in the past 15 years and supportive housing to food assistance deaths from heroin have tripled – could yield between $15 billion and since 2010, contributing to higher $72 billion in healthcare savings a death rates among middle-aged year within 10 years, according to an Whites.18 Five of the strongest school- analysis by TFAH and Healthsperien.24 based substance use prevention l R educing the $120 billion spent strategies have returns on investment annually on preventable infectious ranging from $3.8:1 to $34:1.19, 20, 21, 22 diseases.  Fifteen years after 9/11 and l S aving more than $16 billion 11 years after Hurricane Katrina, when through a more active and healthy health crises such as new infectious population. One in three children will diseases arise, the country often does not develop type 2 diabetes in their lifetime have sufficient funding and capabilities in and one in four young adults are not place to effectively respond.  Preventable healthy enough to join the military.  An infectious diseases cost the country more investment of $10 per person in proven, than $120 billion annually – and that cost evidence-based community prevention is exponentially compounded when new programs to increase physical activity, diseases emerge.25 EXAMPLES OF RETURN ON INVESTMENTS FOR PREVENTION EFFORTS (Analyses/formulas indicate healthcare and/or societal dollars saved for every $1 invested.) Five Strongest Community-based School-based Nutrition, Activity 3.80:1 to Lead Abatement 17:1 to Substance Misuse and Tobacco 5.60:1 Prevention 34:1 Prevention Programs31 221:1 Programs26, 27, 28, 29 Programs30 Supportive Diabetes Early Childhood Housing Programs 2:1 to 4:1 to Prevention 2:1 Education for High-Need 6:1 Program33, 34 Programs35 12:1 Patients32 Child Asthma Nurse Home 1.46:1 to Prevention Visiting for High 5.70:1 Programs36, 37 7:1 Risk Infants38 16 TFAH • healthyamericans.org SECTI O N 2: Rising SECTION 2: RISING EPIDEMICS — AND EFFECTIVE INVESTMENTS TO CURB CRISES AND CUT COSTS Rising Epidemics — and Effective Investments to Curb Crises and Epidemics Cut Costs Communities across the country face serious, ongoing health problems — a majority of which could be prevented or mitigated by prioritizing strong public health programs and strategies. The stakes could not be higher. For 15 years.42 Nationally, more than 2 instance: million Americans misuse prescription drugs, and nearly a half million l H ealth Security for Disease Outbreaks, are addicted to heroin, costing the Disasters and Bioterrorism:  With the country more than $55 billion a year exception of one-time-only funding in healthcare, workplace and criminal for Ebola and Zika, investment in justice spending.44, 45 46, 47 CDC plays preparedness and response to health a critical role by providing support emergencies has been cut by more to states and healthcare providers to than one-third over the past decade. monitor and control the inappropriate CDC has responded to more than 750 prescribing of opioids. health emergencies in the past two years alone.39 There currently is no • nvesting $1 in substance use I funding for a standing Public Health prevention could realize as much Emergency Fund — so when new as $34 in return.48, 49, 50  Five of the emergencies arise, they divert attention strongest school-based substance and resources from ongoing priorities. use prevention strategies have returns on investment ranging from • nfectious diseases cost the country I $3.80:1 to $34:1. more than $120 billion per year, and that cost grows exponentially when l besity and Diabetes:  Nearly 38 O major new diseases strike.40  Every percent of American adults are year, for the past 30 years, one new obese and more than one-third of contagious disease has emerged children are overweight or obese, on average. Moreover, new severe contributing to more than $200 pandemics have the potential to billion in direct healthcare costs disrupt the global economy. For each year.51, 52, 53 Moreover, it creates example, a severe new pandemic additional immediate and long-term could cost the country more than challenges. One in three children $680 billion, or 5.5 percent of the develop diabetes in their lifetime, gross domestic product.41 Experts and one in four are not healthy estimate a 21st century worldwide enough to serve in the military by APRIL 2017 pandemic could cost the global the ages of 17 to 24.54, 55 economy in excess of $6 trillion.42 • nvesting in evidence-based I l P rescription Painkiller and Heroin community health improvement Misuse:  Deaths from opioids have programs could save billions more than quadrupled in the past through a more active and healthy TFAH • healthyamericans.org 17 population. An investment of $10 services (including education, How a 10 percent increase in spending per person in proven, evidence- income support, transportation, on selected social services (2008–2012) based community prevention environmental programs, housing affected county health outcomes programs to increase physical and public safety) in comparison rankings (2012–2015) activity, improve nutrition and to spending on healthcare services K-12 education reduce tobacco use could save the (Medicare and Medicaid) for a country more than $16 billion 10-year period had better health annually — a $5.60:1 return.56 outcomes, including reductions in Fire prevention obesity, asthma, mentally unhealthy l D eclining Life Expectancy:  Life days, days of activity limitations and Corrections expectancy in the United States has mortality rates from type 2 diabetes, declined for the first time in two acute myocardial infarction and Libraries decades. While death rates are higher lung cancer.61 among Blacks and other people of Community healthcare & public health color, death rates have increased the • Connecting health and social fastest (by 10 percent since 1999) services can also cut billions in Public hospitals among middle-aged White men and costs and reduce preventable women (ages 45 to 54).57 Increasing deaths. Health and social service Housing & communuty development death rates among middle-aged Whites coordinating systems that address are the highest in West Virginia, gaps between medical care and 0 1 2 3 4 5 6 7 Mississippi, Oklahoma, Tennessee, effective social service programs Improvement in ranking Kentucky, Alabama and Arkansas.58 — by connecting patients in need with programs ranging Source: Health Affairs, November 2016 • ncreasing local public health I from supportive housing to food spending has shown improved assistance — could yield between health outcomes. One study found $15 billion and $72 billion in a 10 percent increase in spending healthcare savings a year within 10 led to returns, for example, of years, according to an analysis by decreased heart disease by more TFAH and Healthsperien.62 A 16- than 3 percent and infant deaths year long-range analysis found that by almost 7 percent.59 Another communities expanding population study found that government health activities through multisector spending on health and related collaborations and networks had factors that impact health showed lower preventable death rates — with improvement on the County Health mortality due to flu, heart disease, Rankings index from the Robert diabetes and infant death more Wood Johnson Foundation (RWJF) than 20 percent lower, and cancer and University of Wisconsin.60 deaths lower by 14 percent in these And another study found that communities.63 states with increased spending on public health and social 18 TFAH • healthyamericans.org SECTI O N 3: Recommendations SECTION 3: RECOMMENDATIONS Recommendations America’s future economic well-being is inextricably tied to the health of its communities and people. 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 achieve the vision of a modern public responsible for keeping Americans health system, TFAH recommends: healthy and safe. Public health is l I ncreasing funding for public health — devoted to preventing disease and at the federal, state and local levels — injury. Keeping Americans healthier to turn the tide of health epidemics would significantly drive down trips to and prevent disease. Stable, sufficient the doctor’s office or emergency room, funding is required to support basic reduce healthcare costs and improve public health capabilities around the overall productivity. country and to ensure all Americans Public health departments have a are protected no matter where they live. unique role and responsibility — to Increased funds are needed to fill gaps protect citizens from health threats and in critical infrastructure and allow for serve as the Chief Health Strategist for innovation to keep pace with modern communities — working to improve technology. Funding should be health in neighborhoods, schools and strategic and accountable so resources workplaces. They identify the most are used efficiently to maximize pressing health challenges, the most effectiveness and improve health. effective strategies to address them and l M odernizing the public health system work with public and private partners to address gaps in critical infrastructure from across a range of sectors to bring and support innovation. Increased the necessary resources and expertise resources are needed to fill gaps in together to make change happen. the public health infrastructure to Without a strong investment in ensure the basic abilities to detect, prevention, the country will never diagnose and respond to health threats advance in the fight to prevent diseases are maintained — and to keep pace and curb epidemics. Achieving a with advances in technology and healthier nation is a goal all Americans systems. Gaps in key areas of critical share — and greater investment in the infrastructure at CDC and state and nation’s public health system is a sound local health departments must be and powerful approach. addressed — and new resources are APRIL 2017 required for public health to keep pace with modern advancements in technology, approaches and strategies for keeping Americans safe and well. Innovation has been hampered — including development and wide-scale use of state-of-the-art biosurveillance, disease diagnostics and medical countermeasures — due to inadequate resources. Every community should be able to protect its citizens by having the basic abilities to detect, diagnose and contain threats. Investment in innovation is essential to retain the U.S. public health system’s premier global capabilities. l C reating a standing Public Health to maintain the frontline public health departments play a critical role as their Emergency Fund for immediate use emergency workforce and maintain partnership’s Chief Health Strategist. when new threats arise. Ongoing modern infrastructure as well as a l E xpanding the use of evidence-based, funding is essential to prepare complementary surge fund to be able high impact strategies to improve for health emergencies — CDC’s to use to respond to the problems health in every community. Experts Emergency Operations Center was created when a new emergency arises. at the CDC, National Institutes of activated 90 percent of the time l S upporting better health — and top Health (NIH), SAMHSA, public last year, and states and localities local priorities — in every community. health agencies, healthcare systems are continuously responding to There should be improved and other expert organizations have outbreaks, natural disasters and local mechanisms and funding that provide been identifying a growing set of emergencies. CDC scientists have the flexibility for local communities the strongest health improvement responded to more than 750 health to prioritize and address their top strategies, allowing local communities emergencies in the United States and goals — from prescription drug and health systems to share best worldwide in just the past two years. misuse to obesity to adverse childhood practices, and better determine which But the country has lacked a standing experiences. This should include strategies best align with their unique fund to be able to quickly provide bringing together the key partners, needs. Ensuring greater data exchange surge funds when new emergencies assets and resources of a community to and the ability to scale strategies would or outbreaks happen. This means achieve a more efficient and effective dramatically improve the health of resources and attentions are diverted collective impact, including strategies Americans. For instance, in 2016, CDC away from existing threats to deal with better reflecting both their unique released a set of top community-wide a new, immediate threat. The country challenges and expertise. Partners Health Impact in 5 Years strategies and should not be caught off-guard without should include leaders and institutions community-clinical approaches via the the resources needed to counter a new across an entire community 6|18 Initiative: Accelerating Evidence pandemic, disease or bioterror attack. including the health sector and social into Action.64, 65 In addition, a network A Public Health Emergency Fund services, but also local businesses, of expert institutes should be supported would immediately make resources philanthropies, schools and faith and in every state to be able to provide available to fight new pandemics, community groups. This approach support to local communities to help disease outbreaks or bioterror leverages partner expertise as well as identify their top needs and effective threats — while maintaining a strong creates support for a diversification of strategies for addressing them, measure baseline infrastructure for ongoing public and private funding streams. impact and provide technical assistance. readiness. But, there also needs to be Additionally, state and local health ongoing investment in preparedness 20 TFAH • healthyamericans.org SURVEY FINDS 73 PERCENT SUPPORT INVESTMENTS TO IMPROVE HEALTH: OBESITY AND FUTURE HEALTH OF CHILDREN ARE TOP CONCERNS A national survey of registered voters found where they live (66 percent rate their own l 6 0 percent highly support treating that nearly three-quarters (73 percent) of health as 8-10 (very good) on a 10-point substance use, including addiction to Americans support increasing investments scale, but only 36 percent rank their com- prescription painkillers and heroin, like a to improve the health of communities.   66 munity’s health as very good).  There are disease, not a crime; Support spans across party lines (57 per- differences based on income, age, educa- l 6 0 percent highly support planning for cent of Republicans, 87 percent of Demo- tion and area of the country regarding how building more parks, walking and biking crats and 70 percent of Independents) and people rank their health.  For instance: trails and other recreation areas for people regions of the country (75 percent in the l 7 3 percent of college-educated Whites to be physically active in all communities; Northeast, 71 percent in the Central U.S., rank their health as very good compared l 6 0 percent highly support increasing ac- 72 percent in the South and 75 percent in to 57 percent of Whites without col- cess to safe and affordable housing and the West).  Women are the strongest pro- lege degrees; and 72 percent of indi- routinely testing for things that create ponents of supporting health improvement viduals with a household income above health problems in homes, like lead in efforts (62 percent of Republican women, $50,000 per year rank their health as water and paint, carbon monoxide and 87 percent of Democratic women and 80 very good compared to 59 percent of harmful chemicals in the air; percent of Independent women). those with incomes below $50,000. l 5 9 percent highly support increasing The survey was conducted by Greenberg A majority of American registered voters incentives that encourage business Quinlan Rosner Research, in consultation also strongly support (rating 8-10 out of owners to open grocery stores in with Bellweather Research, on September a 10-point scale) a range of priorities and communities that lack access to healthy 8-9, 2016 of a nationwide sample of 1,302 strategies for improving health, including: food options; and registered voters across the country. l 7 4 percent of people highly support provid- l 5 8 percent highly support building local A majority (51 percent) believe that today’s ing enough time — during the school day partnerships across businesses, health children will be less healthy than previous and afterschool — for kids’ physical educa- systems, schools and community organi- generations when they reach adulthood.  tion, physical activity or community sports; zations to address specific health prob- The groups who hold this belief most l 7 4 percent also highly support creat- lems in communities.  strongly include: Republicans (55 percent); ing partnerships among farmers, food Methodology:  On behalf of the Robert Wood Johnson rural residents (60 percent); Southerners suppliers and community health groups Foundation and the Trust for America’s Health, (57 percent); Independent women (62 to bring fresh produce trucks or mobile Greenberg Quinlan Rosner Research, in consultation percent); and Black women (68 percent).  markets to communities that lack ac- with Bellwether Research, conducted a survey among 1,320 registered voters nationwide (1,019 weighted). Most registered voters with children under cess to grocery stores; The survey was conducted between September age 18, however, believe their own children 8th and 9th, 2016. Voters were randomly selected l 6 5 percent highly support providing kids are very healthy (92 percent give an 8-10 from a list of registered voters and reached on a with more information on making healthy rating on a 10-point scale); this is the case landline or cell phone depending on the number they food choices and being physically active; designated on their voter registration. Interviews were for parents of all ideologies, incomes, edu- conducted by live telephone interviewers; 50 percent cation levels and ethnicities. l 6 3 percent highly support investing more were reached on a cell phone. Included in the sample in preventing obesity and chronic diseases were three oversamples: 100 Black voters, 100 Additionally, 64 percent believe that the num- like heart disease, diabetes and stroke; Hispanic voters and 100 White non-college voters. ber of health issues facing the country has Upon completion of the survey, the results were l 6 2 percent highly support increasing early grown in recent years. Obesity is the top weighted to make the three oversampled groups childhood health programs, including home proportional to the racial and ethnic composition of health concern (41 percent), cancer ranked visit programs, mobile health screenings registered voters nationwide. The data was weighted second (33 percent), followed by heart dis- to reflect the total population of registered voters, and treatment for diseases like asthma;  ease and stroke (14 percent) and diabetes taking into account regional and demographic and substance misuse (both at 11 percent).  l 6 1 percent highly support investing characteristics according to known census estimates more in preventing the spread of infec- and voter file projections. The data are subject to a Americans also rate their own health margin of error of +/- 3.1 percentage points.  Full tious diseases like the Zika virus, bird survey and topline results are available upon request.  better than the health of the community flu and hepatitis; TFAH • healthyamericans.org 21 Endnotes 1 nstitute of Medicine. The Future of the Pub- I www.healthyamericans.org/reports/ 23 Trust for America’s Health (TFAH). Preven- lic’s Health in the 21st Century. Washington, readyornot2016/ (accessed February). 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