OPINION: A plan for reinvesting in U.S. public health system

Confronting a legacy of scarcity in U.S. funding for public health - STAT Decades of underfunding public health have left Americans vulnerable to Covid-19 and future calamities that are just around the corner. Patrick Skerrett STAT

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.

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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. ...

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. ...