US Public Health Neglected: Flat Or Declining Spending Left States Ill Equipped To Respond To COVID-19

Abstract

The COVID-19 pandemic has prompted concern about the integrity of the US public health infrastructure. Federal, state, and local governments spend $93 billion annually on public health in the US, but most of this spending is at the state level. Thus, shoring up gaps in public health preparedness and response requires an understanding of state spending. We present state spending trends in eight categories of public health activity from 2008 through 2018. We obtained data from the Census Bureau for all states except California and coded the data by public health category. Although overall national health expenditures grew by 4.3 percent in this period, state governmental public health spending saw no statistically significant growth between 2008 and 2018 except in injury prevention. Moreover, state spending levels on public health were not restored after cuts experienced during the Great Recession, leaving states ill equipped to respond to COVID-19 and other emerging health needs.

EXHIBIT 1. State governmental spending trends in public health activities, 2008–18

SOURCE Authors’ analysis of data from the Census Bureau, Census of Governments, 2018. NOTE Per capita expenditure values are real (inflation-adjusted) 2018 US dollars.

Exhibit 3. State spending trends, by public health category, 2008–18

SOURCE Authors’ analysis of data from the Census Bureau, Census of Governments, 2018. NOTES Negative values may be observed. These values likely reflect reconciliation efforts or intra-agency transfers. These negative values are included in the census data set (and thus also are included in the final estimates put out by the Census Bureau). Each category includes 539 observations (eleven years times forty-nine states).