State-level spending on public health by all governmental agencies: Using Census of Government data to create a new finance dataset for the field

background:

The National Health Expenditure Accounts (NHEA) public health activity estimate is frequently used as an estimate of the nation’s governmental public health expenditures. However, it has been posited that actual public health spending is lower than the NHEA estimates. 

research objective: Re-code Census of Government state agency expenditure data to assess the accuracy of the NHEA Public Health Activity estimate.

study design: We dual-coded state agency expenditure data to ascertain 1) whether the expenditure record was recognized as public health under the Foundational Public Health Services (FPHS) model and 2) if it was characterized as a public health expenditure, to determine the type of spending. We compared spending by state, year, type, and examined drivers of non public health spending. 

population studied: Expenditure data from all U.S. State government agencies, FY2000-FY2012.

principal findings:

Coding revealed approximately 1.05 million state agency budget line items in the FPHS public health definition ($202 billion), and 682,445 items not public health ($253 billion) FY2000-2012. Leading non-public health categories included Behavioral health, Human Services, Health Care Financing, and Environmental Protection. Our refined estimates suggest that less than half of the Census public health activities are actually public health, suggesting NHEA’s estimates of Public Health Activity spending might be significantly larger than actuals.

conclusions and implications: Findings suggest that governmental public health spending might be significantly lower than current estimates. This has implications as to approaches, investments, and partnerships that might be needed to secure and sustain a FPHS public health model.