A study published in a new supplement to the American Journal of Public Health investigates the extent to which public health activities in metropolitan areas suffered during the recent recession. In "Economic Shocks and Public Health Protections in US Metropolitan Areas," Glen P. Mays and Rachel A. Hogg of the University of Kentucky's College of Public Health used National Longitudinal Survey of Public Health Systems data on 280 US metropolitan areas from 1998, 2006, and 2012 to examine changes in the implementation of 20 core public health activities. These range from investigating adverse health events and performing public health laboratory testing services to conducting community health needs assessments and developing community health improvement plans.
Between 2006 and 2012, a composite measure of all activities declined by slightly less than five percent -- but the drop was far more substantial in some metro areas and for some kinds of activities. When the authors divided the metropolitan areas into quintiles by the extent to which recommended public-health activities decreased or increased, they found that the lowest quintile showed a 25% decline in activity availability. For metro areas overall, the researchers found statistically significant increases in availability of behavioral risk factor surveillance and analysis of preventive services-utilization, while nine activities remained relatively stable and nine saw significant decreases. Mays and Hogg report:
Several public health activities remained nearly universally available during the period of study, including the investigation of adverse health events (available in 99.6% of communities), public health laboratory testing (99.2% availability), and the implementation of legally mandated public health services (89.2% availability) such as vital records collections and notifiable disease reporting.
... The largest reductions in availability between 2006 and 2012 occurred for activities that involved developing plans to improve community health (19.6% reduction), allocating resources on the basis of these plans (25.5% reduction), and implementing quality improvement processes for public health programs (15.3% reduction).
It's not surprising that the researchers found that service delivery fell the most in areas that experienced the greatest reduction in public-health agency spending and household income and the greatest increases in unemployment.
Mays and Hogg report that the recession-related cuts would probably have been even more drastic if the federal government hadn't put additional money into public health through the economic stimulus package and the Affordable Care Act's Prevention and Public Health Fund. They also note that redirection of substantial PPHF money coupled with budget sequestration kept the federal contribution lower than it could have been, though.
The ACA may also be moderating reductions in public-health-service availability indirectly through its effects on various healthcare entities. Mays and Hogg explain, "the contributions to public health activities made by health care delivery system stakeholders such as hospitals, health insurers, and community health centers proved to be much more recession resitsant than were the contributions made by governmental agencies during this time period." In particular, they cite the ACA's requirement for not-for-profit hospitals that get tax exemptions to conduct community health needs assessments and develop community health improvement plans.
The authors warn that cutting back on activities like policy development and planning, as many public-health agencies did during the recession, raises concerns about local capacity to effectively respond to preventable diseases. These efforts require long-term commitments that don't show an immediate payoff, so public officials often find it easier to cut them in difficult budget years. Years of inadequate funding, though, add up to missed opportunities to improve population health.
Mays and Hogg suggest "new, long-term financing instruments such as social impact bonds" to help public-health service providers weather economic shocks. They acknowledge that the federal government may need to play a larger role, too. I'd like to see federal funding for public health increase automatically during economic downturns, rather than relying on Congress to agree to pass an economic stimulus package or other such legislation. Then we wouldn't see important public health functions decline -- and decline most sharply in the hardest-hit communities -- when unemployment rises.