Pulse
What’s in a Number? - June 2010
When the question is about public health spending, the answer depends on who’s counting.
Minnesota has a long-standing reputation for having a healthy population. But when the nonprofit health advocacy organization Trust for America’s Health ranked Minnesota 43rd in state spending on public health in a report released in March, heads turned.
“When I saw this report I thought, ‘That’s really bizarre. It just doesn’t make sense,’” says Edward Ehlinger, M.D., M.S.P.H., director and chief health officer of the University of Minnesota’s Boynton Health Service and a member of the MMA’s Public Health and Preventive Medicine Committee.
Ehlinger wasn’t the only health official to have that reaction about this and earlier reports that showed similar rankings: “Everyone was saying, ‘Huh? Are we that low?’” recalls Rob Fulton, director of the St. Paul-Ramsey County Department of Health.
The answer, it seems, depends on who’s counting and how funding is calculated. According to state and local public health officials, Minnesota lies somewhere closer to the middle. The state’s $77.1 million public health budget for fiscal year 2008-09 does average out to $14.66 per person, putting Minnesota in the 43rd spot; but state general fund spending makes up only a portion of all public health spending in Minnesota, and not even the largest portion. The largest source of nonfederal revenue for public health—about $100 million annually—comes from local taxes and goes directly to Minnesota’s 53 local health departments, says Craig Acomb, assistant commissioner for finance at the Minnesota Department of Health.
The state gets another $15 million per year for public health programs from the Health Care Access Fund, which is funded with a 2 percent fee levied on providers. In addition, the Legislature has allocated an additional $47 million for 2010-2011 for programs to reduce tobacco use and obesity through the newly created State Health Improvement Program (SHIP).
None of that money, Acomb says, is included in the Trust for America’s Health report calculation. But added together with money from the state’s general fund, it puts Minnesota’s public health spending above the national median of $28.92 per person per year, Acomb says. “So it’s just sort of a methodology issue,” he explains.
Elle Hogan of Trust for America’s Health admits the report isn’t a comprehensive assessment of all public health spending in a state but offers a comparison of individual states’ spending on public health. “It’s our view that public health is first and foremost a state responsibility,” Hogan says. “If someone wants to look at the total funding, I agree that would be helpful. But for now, we just measure a state-by-state comparison.”
Decentralized Approach
Minnesota has always had a decentralized public health system. At one time, there were more than 2,100 local public health departments in the state. In 1976, the Legislature passed the Community Health Services Act, which created community health boards (CHBs) based on population and geography. There are now 53 CHBs in Minnesota, 28 of which are stand-alone county boards, 21 multi-county or city-county boards, and four independent city boards. Each of the CHBs gets money from the state’s general fund; but a more significant portion of funding comes from local taxes.
For example, the St. Paul-Ramsey County Department of Health gets about $2.5 million from the state for public health, but that is a small part of its overall budget of $52 million. County taxes account for about $8.9 million. Another $20 million is generated from fees collected by garbage haulers for waste management. That reliance on local funding may make it difficult to track overall public health spending in the state, but that is not the only challenge when trying to gauge public health commitment. Even defining what is a public health concern is somewhat left up to each of the CHBs. The state lays out six broad performance measures, and every CHB must do something within each area. But what and how much is decided at the local level. “The nature of public health and how you define it can be very fluid,” says Acomb.
For example, the Ramsey and Washington CHBs include solid waste management as one of their responsibilities, but others don’t. In Hennepin County, the public health department provides clinic services, but the stand-alone Minneapolis Department of Health and Family Support, which oversees public health for the city, only offers such services in school-based clinics. Nor does Minneapolis do restaurant inspections, a function commonly done by other public health departments. Those duties fall under the city’s Environmental Health Division. Community Health Boards also have spun off some public health duties to private health care providers. For example, Ramsey County owns Regions Hospital, but HealthPartners operates it.
“If you’ve seen one public health department, you’ve seen one public health department,” Fulton says jokingly. “They’re all so vastly different.”
Despite this decentralized approach, or maybe because of it, Minnesota still seems to get the job done. On a slew of health indicators, Minnesota ranks in the top 10 in the nation, according to the Trust for America’s Health report, including percentage of uninsured, infant mortality, and adult tobacco use. “We obviously have figured out a way to do it because we’re a healthy state,” Fulton points out. “Ramsey and Hennepin County had the lowest noninsurance rates of any large counties in the U.S. We really do very well here.”
But is Minnesota doing enough?
Managing Not Thriving
Although Minnesota’s population is healthy compared with much of the nation, our health indicators have been falling. Between 2002 and 2006, United Health Foundation consistently ranked Minnesota the healthiest state in the nation. This year, the state dropped to sixth overall, and seventh in terms of health determinants such as smoking, binge drinking, and obesity.
Ask if public health funding is adequate to meet the state’s needs, most agree that it is not.
“Public health has been chronically underfunded and now when the budget gets tighter and tighter, public health is … I can’t say it’s being disproportionately affected, but it is certainly affected by some of the budget cuts, and it’s aggravating the infrastructure issues that we’ve always had with public health,” says Ehlinger, who worked for the Minneapolis Department of Public Health before signing on with the university. Some of those infrastructure issues include emergency preparedness (such as for dealing with public health concerns like H1N1) and education (about issues such as tobacco use, obesity, sexually transmitted diseases, and teen pregnancy).
In Ramsey County, Fulton says public health funding has declined somewhat, and that has led to some cuts. Ramsey County had eliminated 15 full-time positions out of a total of 330 but was able to reinstate five this year using the county’s $1.4 million allocation of SHIP funds.
The county has also shifted some public health programs to community clinics, including a program to screen incoming refugees for infectious diseases. Part of the impetus for that change, however, is a decline in the number of refugees coming to Minnesota, Fulton says.
“I would not say we’re doing well,” he says. “We’re managing, and we’re focusing our work on the highest priorities.”—J. Trout Lowen