1. JP Leider, Beth Resnick, David Bishai, F. Douglas Scutchfield
How much do we spend? Creating historical estimates of public health expenditures in the US at the federal, state, and local levels
JP Leider, Beth Resnick, David Bishai, F. Douglas Scutchfield

2. Acknowledgements
This work was funded in part by the de Beaumont Foundation. Dr. Leider was a consultant to the de Beaumont Foundation. The authors thank Lava Timsina for processing historical financial data, Mac McCullough for use of historical local data, the US Census Bureau for provision of data, and to the Johns Hopkins State Health Expenditure Dataset team for their support of the project.
The authors have nothing to disclose

3. Public Health Activity estimates (from National Health Expenditure Accounts)

4. Public health finance is much more than CMS’ national estimates
Numerous articles on public health finance
Datasets exist for
Federal
State
Local
National
Special datasets/projects:
PHAST, DACS, SHED, UCA and more

5. Federal sources of data
Catalog of Federal Domestic Assistance (CFDA)
HHS-specific Tracking Accountability in Government Grants System (TAGGS)
Data.gov
Office of Management and Budget historical
Historical records exist in the now-defunct Consolidated Federal Funds Report
Both CDC and HRSA offer grant funding profiles for recent years
But how to define public health?

10. Challenges with federal data
Many agencies – CDC included – do not publish the final location and disposition of sub-awards
CDC will sometimes directly award grants to local health departments that may also receive additional CDC funding via pass-through funds from the state health agency
Unclear if databases reflect spending under the agency’s authority versus both agency spending and other federal sources of funds, (e.g., the Prevention and Public Health Fund)
Further complicated by datasets that may include or exclude mandatory and/or discretionary spending, and whether such budgetary details are explicitly identified to the data user

11. State health spending estimates
ASTHO (1970s-1980s and 2007-present)
US Census
Trust for America’s Health

12. State health agency spending

13. Challenges with State estimates
Estimates from the Census and SHAs (by way of ASTHO) are difficult to reconcile
Where ASTHO collects data on SHAs alone, Census collects it on all state agencies performing public health activities
Census collects data on all health activities (including, separately, Medicaid and public hospital spending) means the scope and scale of spending is quite different between the two estimates.
Increased proportion of state-level non-hospital health spending is going toward personal health care activities – likely especially toward behavioral healthcare and outpatient community health care.

15. Data sources for local health estimates
National Association of County and City Health Officials
US Census Bureau

16. Local level spending on community health care and public health

17. Per capita expenditures at LHDs and on non-hospital health services, 1993-2013

18. Non-hospital health spending (1972)

19. Non-hospital health spending (2012)

20. Where are we now? Are our official estimates correct?
Major national projects
Financial data for use in cost-benefit analyses
Significant challenges
Are our official estimates correct?
Spoilers: No.

21. Revised NHEA estimates
CMS Public Health activity estimate
** JP – perhaps take “range out” and just put line for our revised estimate

22. Questions?