Estimated Expenditures for Core Public Health Functions -- Selected States, October 1992-September 1993

Core public health functions (i.e., essential public health services) are activities that public health departments and other partners undertake to protect and ensure the health of the public. Although total spending for public health programs in the United States has been estimated (1), expenditures for core public health functions have not been characterized. To characterize such expenditures, the Public Health Service (PHS) and the Public Health Foundation (PHF) surveyed senior public health officials in eight states (Connecticut, Illinois, Iowa, Missouri, New York, Oregon, Rhode Island, and Texas {combined 1990 population: 61.4 million}) and used the survey data to estimate national expenditures for core functions during fiscal year 1993 (October 1992-September 1993). This report summarizes the results of that survey (2).

The eight states were selected to reflect geographic and population diversity, and the scope of public health responsibilities of the health agencies in these states varied substantially. Senior public health officials in each state used standard forms and methodologies developed by PHS and PHF to provide state-specific total expenditures and expenditures associated with 10 core public health functions (encompassing surveillance, preventive services, outreach, quality assurance, training, and planning) during fiscal year 1993. Respondents provided the budgets of state and local public health agencies, substance-abuse agencies, mental health agencies, and environmental agencies. State populations were determined from the 1990 census.

Among the eight states, per capita expenditures for core public health functions ranged from $31 to $57 (mean: $44); these expenditures constituted 15%-46% (mean: 27%) of the total expenditures for combined public health agencies in each state. Per capita expenditures for all public health agencies combined in each state ranged from $93 to $275 (mean: $166). Overall, approximately 30% of core public health expenditures were spent by environmental health agencies.

Health expenditures by state and local public health agencies were calculated by excluding substance-abuse, mental health, and environmental health agency expenditures. Per capita expenditures by state and local public health agencies ranged from $42 to $101 (mean: $64); core public health expenditures constituted 30%-61% (mean: 41%) of the total expenditures by state and local public health agencies in each state. Reported by: S Addiss, Connecticut Dept of Public Health and Addiction Svcs. J Lumpkin, Illinois Dept of Public Health. C Atchinson, Iowa Dept of Public Health. C Stokes, Missouri Dept of Health. L Novick, New York Dept of Health. M Skeels, Oregon Health Div. W Waters Jr, Rhode Island Dept of Health. D Smith, Texas Dept of Health. Association of Schools of Public Health, Washington, DC. Association of State and Territorial Health Officials, Washington, DC. National Academy of Sciences-Institute of Medicine, Washington, DC. National Association of County and City Health Officials, Washington, DC. Public Health Foundation, Washington, DC. Health Resources and Svcs Administration, and Office of Disease Prevention and Health Promotion, Public Health Svc; Office of the Assistant Secretary for Health, US Dept of Health and Human Svcs. Div of Public Health Systems, Public Health Practice Program Office, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that to provide the essential services of public health to communities, an average of $44 per capita was spent during 1993 by the eight states included in the survey. Based on this finding and assuming that these states are representative of the U.S. population, during the same period nationally, state and local public health, substance-abuse, mental health, and environmental agencies spent an estimated $11.4 billion (range: $8.0 billion-$14 billion) on core public health functions. * In addition, during this period, PHS spent an estimated $3.0 billion on core public health functions (1). Therefore, during fiscal year 1993, the combined estimated state, local, and PHS expenditures on core public health functions were $14.4 billion (range: $11 billion-$17 billion). Based on an estimate by the Health Care Financing Administration (HCFA), total health-care-related expenditures for the United States in 1993 were $903 billion (3). Thus, core public health functions accounted for approximately 1.6% (range: 1.2%-2.0%) of national health-care expenditures in 1993. If expenditures by environmental agencies and PHS are not considered, only 0.9% was spent on core public health functions. In comparison, HCFA estimated that, in 1993, expenditures for federal, state, and local public health activities were $24.2 billion -- or 2.7% of national health expenditures. In addition, a previous report indicated that, in 1988, prevention-related activities accounted for 3.4% of national health expenditures (4).

The findings in this report are subject to at least two limitations. First, the estimated expenditures are based on the analysis of data from a small, nonrandom sample of states that may not be representative of all states. In particular, the availability and use of resources for core public health functions may vary in relation to public priorities, revenue sources, and other factors. Second, although the core functions were explicitly defined, there were state-specific differences in statutory responsibilities and organization of state public health agencies that, in turn, were associated with variations in expenditures on core public health functions.

Public health functions and services have been defined and classified previously by organizations including the National Academy of Sciences-Institute of Medicine (5), the National Association of County and City Health Officials (6), CDC (7), and some states. To further define the purposes and services of public health, in 1994 PHS convened a workgroup with representatives from multiple public-sector and professional organizations. ** This work group defined six public health responsibilities and 10 essential services of public health Table_1.

In 1988, the Institute of Medicine recommended strengthening the public health system (5). Other organizations have suggested that funding of community-oriented public health functions should be three times higher than the current amount (2,8). The PHS continues to investigate expenditures on public health: nine states are participating in a second pilot study for fiscal year 1994 that will more precisely measure expenditures associated with the essential public health services. State and local health agencies and other partners should continue to examine expenditures on public health activities and ensure that essential public health services are carried out.

References

1. Burner ST, Waldo DR, McKusick DR. National health expenditures projections through 2030. Health Care Financing Rev 1992;14:1-29.

2. Public Health Foundation. Measuring state expenditures for core public health functions. Washington, DC: Public Health Foundation, 1994.

3. Department of Health and Human Services, Assistant Secretary for Management and Budget (Appropriations). Survey of PHS agencies for public health functions. Washington, DC: US Department of Health and Human Services, Public Health Service, 1994.

4. Brown RE, Elixhauser A, Corea J, Luce BR, Sheingold S. National expenditures for health promotion and disease prevention activities in the United States. Washington, DC: Battelle, Medical Technology Assessment and Policy Research Center, 1991.

5. Institute of Medicine. The future of public health. Washington, DC: National Academy Press 1988.

6. National Association of County Health Officials/CDC. Blueprint for a healthy community: a guide for local health departments. Washington, DC: National Association of County Health Officials/US Department of Health and Human Services, Public Health Service, CDC, 1994.

7. Roper W, Baker EL, Dyal WW, Nicola RM. Strengthening the public health system. Public Health Reports 1992;107:609-15.

8. Partnership for Prevention. Prevention: benefits, costs and savings. Washington, DC: Partnership for Prevention, 1994.

* $11.4 billion=$44.35 (spent per capita) multiplied by 258 million (U.S. 1993 population); the range is based on the range of per capita expenditures for the eight states surveyed. 

** Agency for Health Care Policy and Research, American Public Health Association, Association of Schools of Public Health, Association of State and Territorial Health Officials, Food and Drug Administration, Health Resources and Services Administration, Indian Health Service, National Academy of Sciences-Institute of Medicine, National Association of County and City Health Officials, National Association of State Alcohol and Drug Abuse Directors, National Association of State Mental Health Program Directors, Office of the Assistant Secretary for Health, Public Health Foundation, Substance Abuse and Mental Health Services Administration, and CDC.

TABLE 1. Public health responsibilities and essential public health services -- 1994
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Public Health:
o    Prevents epidemics and the spread of disease
o    Protects against environmental hazards
o    Prevents injuries
o    Promotes and encourages healthy behaviors and mental health
o    Responds to disasters and assists communities in recovery
o    Assures the quality and accessibility of health services

Essential Public Health Services:
o    Monitor health status to identify and solve community health problems
o    Diagnose and investigate health problems and health hazards in the community
o    Inform, educate, and empower people about health issues
o    Mobilize community partnerships and action to identify and solve health
     problems
o    Develop policies and plans that support individual and community health efforts
o    Enforce laws and regulations that protect health and ensure safety
o    Link people to needed personal health services and assure the provision of
     health care when otherwise unavailable
o    Assure a competent public health and personal health care workforce
o    Evaluate effectiveness, accessibility, and quality of personal and
     population-based health services
o    Research for new insights and innovative solutions to health problems

Source: Essential Public Health Services Work Group.
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