Confronting a legacy of scarcity: a plan for reinvesting in U.S. public health

Public health in America is in crisis, a sad fact that the Covid-19 pandemic has made impossible to ignore.

Decades of chronic underfunding and a failure to invest in the public health workforce, the physical infrastructure of state and local health departments, and critical data systems have left Americans vulnerable to calamities like Covid-19 and other pathogens that lie just around the corner.

In the last two decades, funding for public health has been progressively chipped away. In the last 10 years alone, funding for state and local health departments has fallen by 17%; the Centers for Disease Control and Prevention’s budget for preparedness and response has been cut in half.

This overall decrease in funding for public health is emblematic of an American willingness to pay more later than invest upfront — of the 18% of the federal budget spent on health care, only 3% goes towards prevention and mitigating disease.

Experts estimate that the U.S. needs to invest an additional $4.5 billion each year to adequately carry out basic but essential activities such as disease surveillance, data gathering and reporting, sanitation, and immunization. In total, this may seem like a huge sum. But taken individually, it means spending an extra $13 per person — a small price to pay for the betterment of millions of lives.

With more than 600,000 American deaths caused so far by Covid-19, the effects of chronically underfunding public health have never been clearer. Now is the time to overhaul the ways in which the U.S. addresses public health, including creating a new set of funding initiatives that are based on long-term sustainability, equity, and flexibility for those who implement these programs on the ground.

Along with several colleagues, we recently published “Confronting a Legacy of Scarcity.” This report, a joint project between Yale University public health and law students, charts the path forward for improving public health in the U.S. To develop the report and the proposals that emerge from it, we spoke to nearly two dozen experts, ranging from local, state, and federal policymakers to academics and on-the-ground practitioners across the country, about how to revive American public health from its precarious state.

Our plan for sustainable public health funding centers around a new, statutorily protected, mandatory funding stream that is shielded against bureaucratic attempts to shift funding away from public health initiatives. The stability and reliability that mandatory funding offers are critical for future success in promoting the nation’s public health by allowing state and local health departments to hire necessary staff, invest in building capacity, and experiment and innovate without worrying about how to perform basic tasks under the constraints of meager year-to-year budgets.

This change, from yearly discretionary appropriations to an insulated fund grounded in the mandatory budgetary process, is a necessary path forward. These long-term, recurring funds should be dedicated to building, or rebuilding, public health infrastructure, including upgrading of crumbling and antiquated health department buildings, updating data systems, and scaling up the public health workforce, all guided by state and local needs.

But a base of new mandatory funding is not enough. The U.S. will also need injections of discretionary funds through annual appropriations processes to bring American public health up to code and into the 21st century. The American Rescue Plan, which offers an additional $93 billion toward public health, is a good start on this investment, but the U.S. public health system needs more. The rescue plan does not provide funding to address the most pressing needs of health departments and the local organizations they work with, things like personnel, physical infrastructure, and disease prevention programs that are currently overshadowed by Covid-19.

In addition to more resources, a better future for American public health requires revamping funding systems to better promote flexibility, accountability, innovation, and equity in local program implementation. Historically, public health funding flows from the federal government to the states, with cities and towns then subject to their own states’ politics rather than their communities’ needs. The choice here is to send more public health funding directly to local communities or to put basic standards in place for how funding should be allocated at the state level, with more local discretion on the use of funds.

This plan isn’t intended to create giveaways to cities and towns with little oversight. Accountability based on population health outcomes — disease incidence and prevalence, progress on confronting the social determinants of health, and the like — is needed in place of the process indicators that currently weigh down grants. These new indicators should be based on gains achieved in communities’ health, as opposed to simple tasks completed.

In addition, tackling the social determinants of health — the social and economic factors that influence individual well-being, such as housing, food, and education — needs to be part of a health-in-all policies approach to funding through incentivizing collaboration among federal, state, and local agencies with responsibilities in these areas.

The racial disparities in sickness and death during the Covid-19 pandemic have recapitulated the gross health inequities that have been endemic in the U.S. for generations. New approaches to supporting health equity must be at the heart of a national public health renaissance.

None of this is going to be easy. The political inertia, in fact, outright resistance to new long-term public health funding is likely to be intense. Yet this moment, before the vivid memories of Covid-19 fade away, may serve as the best opportunity for decades to overhaul American public health. As terrible as the Covid-19 pandemic has been, it will not be our last. The smartest investment the U.S. could make today is to prepare now for the coming plague.

William Eger is a 2021 Master of Public Health graduate from the Yale School of Public Health who works as a research associate for the Yale University School of Medicine on projects related to substance use and HIV/AIDS. Margaret House is a rising third-year law student at Yale Law School whose work focuses on the intersections between health, law, and social justice. Both are among the co-authors of the “Confronting a Legacy of Scarcity” report.