1. The Cost of Foundational Public Health Services and Capabilities: Estimates, Variation, and Disparities Betty Bekemeier, Justin Marlowe, Linda Sharee Squires Keeneland PHSSR Conference—April 21-22, 2015 Funded by RWJF: Deliver and Cost Study (Grant #71132)

2. Overview Our Questions: What does the package of foundational public health services (FPHS) cost? What explains variation in FPHS costs across local health jurisdictions (LHJs)? WA State has developed an FPHS framework that defines and measures foundational activities; we build on that framework Main findings: Actual spending falls well short of spending needed to deliver FPHS Unit costs vary a great deal across LHJs Demographic characteristics and (especially) political climate explain much of the variation in unit costs

3. Empirical Analysis Cost survey completed by three jurisdictions – emphasis on actual spending vs. needs Analysis of administrative data on local health expenditures Integrated the two, leveraging cost functions implied by the survey results Combined FPHS unit costs with demographic and other contextual data

4. Data and Methods Ten Washington LHJs completed a cost data collection instrument Captures direct costs, mainly by identifying FTE effort on each activity within each foundational public capability and service domain Respondents estimate indirect labor and indirect non-labor costs WA State Budget and Reporting System (BARS) (administrative) data for all 35 LHJ in WA fiscal years 2007-2013 Map BARS data to the FPHS framework for multivariate regression

6. Unit Costs Vary Across LHJs

7. What Explains Variation in Unit Costs? Multivariate panel regressions with unit costs for each FPHS area as DV, for FY 2007-2013 Independent variables: population, poverty, unemployment, local voters’ willingness to spend on government services, metropolitan vs. micropolitan area, NAACHO governance variables Includes time fixed effects N = ~245 for each capability/service area, R2 range from.34 -.65

9. Implications and Limitations These findings inform a crucial statewide policy discussion. Two of the key questions within that discussion are: 1) How much new money, or how much reprogramming of existing categorical money, will the state need to authorize to ensure all citizens have access to basic public health services; and 2) Are there policy strategies that can mitigate disparities in citizens’ access to those services? These findings have implications for both questions.

10. Thank You The Robert Wood Johnson Foundation PHAST Team members (Jim Collins, Good to Great, 2001) Great teams have the “right people on the bus.” THANK YOU!