Despite their vital role in the nation’s public health system, state and local health departments have been hit hard by the recession and related budget cuts. Three recent studies provide evidence that the public health system is under severe and increasing pressure, as state and local health departments are asked to take on more responsibilities with fewer resources. The economic downturn has strained the system, and has exposed persistent gaps in the system’s functioning and financing.
Initially, a December 2009 Robert Wood Johnson Foundation-funded report by Health Management Associates, an independent research group, determined that the ability of local health departments to protect and improve health is in jeopardy. The report focuses mainly on the impact of budget cuts on local health departments. Recently, substantial funding cutbacks from local, state and federal government sources have shrunk response capacity in already-strapped local health departments. 
The report’s authors, Jack Meyer and Lori Weiselberg, conducted interviews with small, medium, and large local health departments around the country to collect specific information on the recent budget picture, and the nature and extent of funding cutbacks they have experienced. The authors found that the combination of federal and state budget woes is dealing a “one-two punch” to local health departments that rely on federal and state grants and programs for a significant portion of their funding (and most do). This, in turn, leads to reductions in vital community-based and clinical prevention services that are in high demand right now, because of unemployment and reduced incomes due to the economic downturn. 
Nearly 2,800 local health departments perform a wide range of activities to improve the health of the U.S. population. Yet, less than 5 percent of total health care spending in the U.S. is devoted to public health, and only a fraction of those resources are available to local health departments. The vast majority of our nation’s health resources are devoted to medical services; the U.S. spends more on administrative overhead within the health care system than it does on public health.
Local health departments are found in very diverse settings. A few serve populations that approach 10 million people (e.g. New York, Los Angeles, and Chicago) while some serve very rural areas with less than 1,000 residents. About two-thirds (64 percent) of the nation’s local health departments serve populations of less than 50,000. Yet, nearly half of the US population (about 46 percent) lives in jurisdictions of the 5 percent of local health departments serving populations greater than half a million people. 
Most city and county health departments employ a small number of professional staff to carry out their essential functions, including investigating and responding to health threats, preparing for emergencies, and ensuring that our food is safe. Roughly 155,000 people work for local health departments across the United States. But more than 60 percent of local health departments have fewer than 25 full-time employees, and only 12 percent have more than 100 full-time employees. Occupations include nurses, public health professionals, physicians, environmental health coordinators, nutritionists, health educators, epidemiologists, and emergency preparedness coordinators. 
Local health departments, on average, receive 25 percent of their funding from local sources–including city/township revenue and county revenue. Another 20 percent of local health department funding comes from direct state funds. Federal funds that “pass through” states en route to localities account for another 17 percent of the typical local health department revenues. 
Sixty percent of local health departments are established as units of local government, and over 12 percent are units of a state health agency. Twenty-seven percent are mixed local and state. Both state and local governments are suffering from the severe economic downturn, and unlike the federal government, they must balance their budgets year after year. This requirement forces painful choices among vital public services and the revenue base needed to support such services. 
Specifically, the Meyer and Weiselberg report finds that health department funding cutbacks will translate into an overall deterioration of people’s health due to: higher rates of infectious diseases in communities; fewer community-based interventions to help prevent and control chronic diseases such as diabetes and asthma; and a lower level of preparedness. 
A March 1, 2010 report from the Trust for America’s Health and the Robert Wood Johnson Foundation found that federal spending for public health has been flat for nearly five years, and that states around the country cut nearly $392 million for public health programs in the past year. These cuts leave communities around the country struggling to deliver basic disease prevention and emergency health preparedness services. 
“Chronic under funding for public health means that millions of Americans are needlessly suffering from preventable diseases, health care costs have skyrocketed, and our workforce is not as healthy as it needs to be to compete with the rest of the world,” said Jeffrey Levi, PhD, Executive Director of Trust for America’s Health. “If we are going to improve the health of Americans, we need to fundamentally rethink our approach to funding and managing public health and disease prevention in the United States.” 
Federal funding to states from the U.S. Centers for Disease Control and Prevention (CDC) averaged out to only $19.23 per person in FY2009. The amount spent to prevent disease and improve health in communities ranged significantly from state to state, with a per capita low of $13.33 in Virginia to a high of $58.65 in Alaska. 
States in the Midwest received the least federal funding support for disease prevention at public health, at only $16.50 per person in fiscal year (FY) 2009, according to the analysis. This is $3.30 less per person than the Northeastern states, which receive the highest amount, at $19.80 per person. Western states receive $19.22 per person, while Southern states receive $19.75 per person. 
State funding for public health ranged dramatically across the country, from a low of $3.55 per person in Nevada to a high of $169.92 per person in Hawaii. The national median is $28.92 per person. The funding structure of state and local health departments varies from state to state, with some states relying more on local funds. 
“Public health departments are responsible for finding ways to address the systemic reasons why some communities are healthier than others and for developing policies and programs to remove obstacles that get in the way of making health choices possible,” Levi said. “But right now, public health departments do not have the resources they need to improve health in communities. Our ability to address the geographic and racial/ethnic disparities in health is limited by our failure to invest adequately in creating a modernized public health system.” 
Finally, new data in another report also released on March 1, 2010 illustrates the uphill battle that local public health departments are fighting in the face of budget cuts. The latest job loss survey by the National Association of County and City Health Officials (NACCHO) found that local health departments lost 8,000 jobs in the second half of 2009–compounding the loss of another 8,000 positions in the first half of the year. 
NACCHO surveyed a sample of local health departments nationwide in the months of J
anuary and February 2010. This was the third in a series of nationally representative surveys designed to measure the impact of the economic recession on local health departments’ jobs, budgets, and programs. 
More than a third of local health departments report a lower budget this year when compared to the previous year. When one-time funding from the American Recovery and Reinvestment Act and/or H1N1 supplemental funding is excluded, an additional 15 percent of local health departments report a lower budget, for a cumulative 53 percent of local health departments experiencing cuts to core funding. 
In 2008, NACCHO had found that local health departments had lost 7,000 jobs through budget-related cuts, layoffs, position eliminations, and attrition. In the last six months of 2009, nearly half of local health departments (46%) lost additional skilled people needed to protect the health of their communities as 8,000 local health department jobs were lost. When combined with the previous NACCHO findings, this results in a cumulative 23,000 jobs lost from 2008-2009, approximately 15 percent of the entire local health department workforce in the country. In 2009, an additional 25,000 local health department employees were affected by cuts in working hours or mandatory furloughs resulting from budget cuts. In 14 states, more than 75 percent of Local health departments lost jobs due to layoffs or attrition. 
“While local health departments will do the best job they can with the resources available to them to protect Americans from public health threats, these data sound a warning,” said NACCHO Executive Director Robert M. Pestronk. “The cumulative effects of budget cuts and job losses have taken a major toll on the ability of health officials to respond not only to large-scale emergencies and disease outbreaks like H1N1 influenza, but to the everyday situations for which the health department is the first line of defense.” 
The Meyer and Weiselberg report calls for several new approaches to funding, to sustain the broad range of local public health activities that are vital to keeping Americans safe and healthy. The report recommends that: (a) The federal government should assign high priority to full funding for state and local health departments, through grants from the Department of Health and Human Services and the Department of Agriculture and from agencies such as the Centers for Disease Control and Prevention, Health Resources and Services Administration, the Office of the Surgeon General, the Food and Drug Administration, and the Environmental Protection Agency. (b) The federal government should also provide a dedicated and sustainable source of federal funding to secure the vital activities of state and local public health departments through a new prevention and public health investment fund. (c) Finally, state, city and county governments should make every effort to preserve adequate funding for local and state health departments, even in a difficult economic climate. 
The need for these new funding strategies appears to be self-evident. However, the critical role of local and state health departments in promoting and preserving public health must first be recognized and acknowledged. Our public health system needs substantive and consistent funding, and deserves to be a higher priority in all relevant budget decisions.
 Jack Meyer and Lori Weiselberg. “County and City Health Departments: The Need for Sustainable Funding and the Potential Effect of Health Reform on Their Operations.” A Report Prepared by Health Management Associates for the Robert Wood Johnson Foundation and the National Association of County & City Health Officials. December 2009.
 “Flat Federal Funding and Cuts in States Put America’s Health at Risk”, Trust for America’s Health press release, March 1, 2010
 “Local Health Department Job Losses and Program Cuts: Overview of Survey Findings from January/February 2010 Survey”, The National Association of County and City Health Officials, March 1, 2010, available at www.naccho.org.
 “New NACCHO Survey Shows Local Health Departments Lost 16,000 Jobs in 2009”, NACCHO press release, March 1, 2010.