How We Reported ‘Underfunded And Under Threat’

To assess the state of the public health system in the United States, KHN and The Associated Press analyzed data on government spending and staffing at national, state and local levels.

What reporters found was a mix of survey and budget data, each measuring a slightly different concept of “public .”

Some datasets track only state public health systems, not agencies that operate at a county, city or regional level. Other data, including some from the U.S. Census Bureau, covers spending on all non-hospital health care. Public health efforts are mixed in with the costs of providing local medical transportation, running community clinics and offering mental health services.

The lack of comprehensive data specifically about public health makes assessing community programs, agencies and staffing levels difficult, experts say. Public health information is scattered and can't be easily compared, unlike data about hospitals and medical treatment, according to Betty Bekemeier, a public health systems researcher and professor at the University of Washington. She is seeking to fix this as the leader of a multistate effort to standardize local health department spending data.

“We will not be able to improve our systems if we don't have a better idea of how it works,” she said.

KHN and AP calculated 2016-18 average annual state spending directly on public health initiatives using the State Health Expenditure Dataset. To create the dataset, a team of researchers encoded data from the Census Bureau's “Annual Survey of State Government Finances,” isolating public health costs to get the clearest sense of what governments spend only on public health efforts.

The data includes spending by all state agencies and their transfers to local governments. To account for inflation for this and all spending data, KHN and the AP adjusted amounts to 2019 dollars using a price deflator from the Bureau of Economic Analysis targeted toward government expenses.

A decade of data on state public health agencies' expenditures and full-time equivalent staffing came from the Association of State and Territorial Health Officials. The data was reported directly by the state public health agencies through a national survey.

When creating national percentage change estimates, reporters excluded a handful of states missing comparable spending or staffing data.

The analysis included census finance data from state and local governments to compare spending on non-hospital health with other priorities such as policing and highway construction and maintenance.

At the local level, the National Association of County and City Health Officials' “National Profile Study” surveys local health departments every three years and weights answers to account for nonresponse.

Beyond that, some states collect local health department spending and staffing data. Reporters used detailed data on local health departments in Florida, Minnesota, Missouri, North Carolina, Ohio and Washington — along with census population estimates — to examine per capita trends over time.

Finally, AP statehouse reporters posed an identical set of questions to states to get a sense of recent and upcoming budget and staffing changes to state public health departments. The AP gathered responses from 43 states.

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