U.S. public health funding steadily falling, new study shows

$40 billion loss of funds since 2009 — and it’s already making a difference to our health, say Fred Hutch experts
person being vaccinated
A new study has found that public health funding, which drives programs in disease prevention, including vaccination, has been steadily falling since 2002. Photo by Sean Warren via iStock

They may not be as sexy as a promising new drug to fight disease, but public health initiatives like smoking cessation, disease prevention and vaccination efforts can save millions of dollars and, more importantly, millions of lives.

Unfortunately, funding for those efforts has dropped significantly over the last few years — and will continue to decline if circumstances don’t change, a new study has found.

Researchers from City University of New York (CUNY) School of Public Health looked at national health spending over the past 53 years and found that out of total health expenditures, funding for public health rose from 1960 to 2002 but has flattened and fallen significantly ever since.

In 1960, public health funding made up 1.36 percent of total health spending, with $39 spent per capita (in inflation-adjusted 2014 dollars). By 2002, when public health spending briefly surged in the wake of the 9/11 attacks, it comprised 3.18 percent of total health spending or $275 per capita. The growth in spending over these decades, the authors found, was primarily driven by an increase in state and local government money, which accounted for between 80 to 90 percent of the influx.

By 2008, public health spending was $281 per capita or 2.96 percent of the total amount of money spent on health. And it has continued to steadily fall. 

Dr. Garnet Anderson
Dr. Garnet Anderson, director of Fred Hutch's Public Health Sciences Division, called the drop in public health funding "disturbing." Photo by Stefanie Felix for Fred Hutch

‘Public health funding has languished’

By 2014, public health funding had plummeted 17 percent from 2002 levels (a 9.3 percent drop since 2008) with just 2.65 percent of total health spending, or $255 per capita, devoted to public health initiatives like smoking cessation and disease prevention. That adds up to a $40.2 billion loss of funds that could have been devoted to public health between 2009 and 2014, the study authors said.

Dr. Garnet Anderson, director of the Public Health Sciences Division at Fred Hutchinson Cancer Research Center, decried the drop in crucial health support.

“The lack of support for disease prevention is disturbing and I believe we are already beginning to see these funding constraints manifest themselves in public health,” she said, pointing to recent backslides in the control of communicable diseases through vaccination programs and health education.  “We have seen outbreaks of whooping cough and measles recently — diseases that had nearly disappeared in the U.S.  This is a shameful reversal of the tremendous progress that had been made.”

And it may get worse, according to forecasted numbers in the report. The researchers looked ahead at the coming decade and projected that by 2023, public health spending will make up just 2.4 percent of total health dollars — a decline of 25 percent in just over 20 years.

“It is clear that public health funding has languished over the past decade,” authors Drs. David Himmelstein and Steffie Woolhandler concluded in their study, published Thursday in the American Journal of Public Health. “The Affordable Care Act originally promised a $15 billion boost in public health funding. However, a 2012 law cut funding for the [ACA’s] Prevention and Public Health Fund by $6.25 billion. Sequestration, which cut federal spending across the board beginning in 2013, reduced it even further.”

Data for the study was drawn from the National Health Expenditure Accounts, compiled annually by the U.S. Department of Health and Human Services, which classifies health expenditures into categories. Public health funding categories are defined as epidemiological surveillance, immunization services, disease prevention programs and the operation of public health laboratories. Government funding for health research, capital purchases and health-related public works (think sewage treatment) are excluded.

Most federal public health money flows from the Food and Drug Administration and the Centers for Disease Control and Prevention, or CDC. Since 2001, substantial public health funding has also come from the Department of Homeland Security and the Public Health and Social Services Emergency Fund.

But it is clearly not enough, stated the authors.

Dr. Jonathan Bricker
Smoking cessation researcher Dr. Jonathan Bricker said our society doesn't seem to value prevention despite the fact it is powerful, effective and much more inexpensive. "It's far more cost-effective than clinical treatment when you consider the millions of lives it can save or prolong," he said. Photo by Robert Hood / Fred Hutch News Service

‘Dangerously out of balance’

“This year, public health will get less than half of the $2 billion promised by the ACA,” said lead author Himmelstein, a professor at CUNY’s School of Public Health and lecturer in medicine at Harvard Medical School. “And state and local government public health spending has also fallen, even while their other health expenditures have continued to rise."

Co-author Woolhandler, a primary care doctor, public health professor at CUNY and a lecturer at Harvard Medical School, minced no words with her criticism regarding the lack of public health spending. 

“Our health care system is dangerously out of balance; we’re spending more and more treating disease but less and less to prevent it,” she said. “We’re breaking the bank paying for hepatitis C and cancer drugs, while drug abuse prevention, needle exchange programs and anti-smoking campaigns are starved for funds.”

Himmelstein and Woolhandler are co-founders and leaders of Physicians for a National Health Program, a nonprofit organization that advocates for a single-payer health system.

The value of prevention

Dr. Jonathan Bricker, a Fred Hutch public health researcher and psychologist who specializes in smoking cessation, also referred to the report as disturbing but said he was not surprised, considering our cultural penchant for immediate gratification.

“We are a culture that has yet to fully value prevention,” he said. “We want immediate results and payoff. Prevention doesn't work that way. It's slow, so its powerful and positive consequences are often not felt for many years.” 

Prevention is also incredibly effective. Case in point, the CDC on Thursday released new statistics that showed the percentage of U.S. adults who smoke cigarettes declined from 20.9 percent in 2005 to 16.8 percent in 2014.

In other words, the number of smokers in the past 10 years took a 20 percent nose dive. Why?

The number one reason cited by the CDC for the drop was anti-smoking campaigns, i.e., prevention.

‘More lip service than support’

“The saddest part of this story is that prevention is actually inexpensive and far more cost-effective than clinical treatment when you consider the millions of lives it can save or prolong,” Bricker said.

“And the increased spending on prevention would have negligible impact on clinical spending. Both are needed and both have an important place in our national healthcare system. It's time our culture starts to see the benefit and start to demand the needed, yet so modest investment."

Anderson also stressed the importance of prevention and said she would love to see a similar analysis of government funding allocations for research just on that.

“Prevention research fuels the pipeline for new strategies to prevent disease and improve health and we sorely need efficacious approaches to stem the obesity epidemic and better approaches to decrease tobacco use,” she said.

“Advances in either of these areas would have broad impact on public health but these topics often seem to get more lip service than actual support.”

What do you think about the sharp drop in public health funding? Tell us about it on Facebook.

Diane Mapes is a staff writer at Fred Hutchinson Cancer Research Center. She has written extensively about health issues for NBC News, TODAY, CNN, MSN, Seattle Magazine and other publications. A breast cancer survivor, she also writes the breast cancer blog doublewhammied.com. Reach her at dmapes@fredhutch.org.

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