Public health programs are long-term investments in the safety and wellbeing of entire communities. Yet, in the years leading up to the Covid-19 pandemic, funding for this critical field has remained flat or decreased across the country even as spending on health care has increased. Louisiana is no exception. Since the Great Recession, state funding for the Louisiana Office of Public Health (OPH) has fallen by nearly one-third even as spending on health care has risen by more than two-thirds.
In Louisiana, the state contribution to the Office of Public Health has fallen precipitously, from a high of $83 million (or about $20 per Louisiana resident) before the Great Recession to a low of $55 million (or about $12 per Louisianan) today. Similarly, the OPH workforce has shrunk by 30% from 1,742 staff (or about 1 per 2,500 Louisianans) in 2008-2009 to 1,229 (or about 1 per 3,800 Louisianans) for the current year. If Louisiana had simply maintained its investment at pre-recession levels, our communities would have reaped the benefits of nearly 9.4 million more hours and $380 million more in public health investments.
The Covid -19 pandemic is straining already underfunded state and local public health systems. The mortality and infection rates of the disease dwarf infectious disease outbreaks of past decades, especially in early hot spots like Louisiana. An estimated 6.3 million Americans have been diagnosed and 189,147 have died as of publication. Louisiana has suffered one of the highest per-capita death rates in the country, with Black and brown communities bearing the health and economic brunt of the pandemic. In Louisiana, more than 154,000 Covid-19 cases have been diagnosed and 4,970 Louisianans have died. Roughly half of all Covid-19 deaths are among Blacks, who comprise 32% of the state’s population.
Sustained cuts to public health makes for sicker communities, and leaves already vulnerable individuals even more exposed when threats like Covid-19 strike. Studies have shown that public health is a proven and cost-effective way to reduce the spread of infectious diseases, develop and deploy life-saving immunizations, limit the harm caused by chronic diseases, and promote community health through shared information and coordinated systems. Despite these proven advantages, public health is often an easy target for budget cuts.
Unlike direct spending on health care services such as doctor visits and hospital care, investments in public health often take place behind the scenes. Patients see their doctor, but they don’t see the effective health-screening tool she uses to identify and treat people at high risk of chronic disease, or the complex databases epidemiologists use to track and curb the spread of infectious diseases such as Covid-19, or the decades of research behind a child’s life-saving immunization. In addition, public health offices are also charged with enforcing sanitation codes, operating laboratories, and monitoring air and water quality. When nothing bad happens, public health departments are doing their job.
Unfortunately, this invisibility can also lead to complacency. In the absence of a public health emergency – when funding tends to spike – elected officials can easily lose sight of their importance. Unwilling to raise the revenue necessary to adequately invest in communities, policymakers make cuts in the short term only to pay more in the long term in the form of sicker communities, higher health care costs, and slower responses to new threats.
In Louisiana, the Office of Public Health budget was cut repeatedly in annual and mid-year cuts following the Great Recession. In the five-year period between 2009 and 2014, nearly 500 positions were cut – about one- third of the workforce. Staffing levels today remain about where they were in 2014. Federal funding, which comprises the majority of the Office of Public Health budget, has increased modestly over time, but even with episodic increases in federal grants to combat outbreaks like the Zika virus and H1N1, combined state and federal funding remain below pre-recession levels. This means fewer dollars and fewer professional staff to fight chronic and communicable disease, ensure water and food supplies are safe for the public, manage public health data, and train and prepare for hurricanes and other natural disasters.
In response to Covid-19, the federal government has provided one-time funding to the Louisiana Office of Public Health. The Center for Disease Control allocated $176 million to combat Covid-19, including testing, surveillance and contact tracing. The CARES Act provided $1.8 billion to Louisiana’s state and local governments, $30 million of which was allocated to OPH. But, according to state budget documents, this CARES Act money will be used to replace state general funds in an effort to fill the nearly $1 billion state budget shortfall caused by Covid-19. This influx of federal funds is necessary to help Louisiana through the current public health crisis, but does little to address underlying issues.
Louisiana made an important investment in health care in 2016 by expanding Medicaid eligibility, granting access to health care coverage to 500,000 low-income adults. This policy decision brought 14,000 local jobs and $1.7 billion a year in federal dollars into Louisiana’s private health care industry, money that supports physicians, nurses, pharmacies and health insurance professionals employed by the private Managed Care Organizations (MCOs) that administer the program. However, health care is not a replacement for public health. Truly healthy communities require both.
The state has made small gains in improving public health investments, but much more remains to be done. The Office of Public Health launched a pilot program in rural St. Landry parish in 2019 that has shown promise in addressing the social determinants of health by connecting people in that community with resources, services, and supports. The program employs three community health workers with the goal of reducing utilization of emergency departments, improving care coordination, reducing health system costs and improving patient well being. With sustained funding, this promising program could be expanded to other parts of the state. One-time, Covid-19-related federal funding is being used to hire fifteen additional community health workers across the state with a focus on contact tracing, resource referral and community outreach.
Research has shown that sustained investments in public health come with a strong return on investment – 14 to 1 according to one study. The Louisiana Health Report Card, which is produced by the Office of Public Health, is full of examples where sustained investments would make a difference in the lives of Louisianans, and where the cost of doing nothing is simply too high. For example, additional investments could fully fund a coordinated and sustained effort to combat obesity, which costs millions in additional medical expenses per year and impacts 36% of Louisianans. It could allow for a stronger response to the opioid crisis, which continues to claim the lives of thousands of Louisianans each year. Or, further reduce the prevalence of cigarette smoking, which is still the leading preventable cause of death in America.
Today’s novel coronavirus has brought new urgency to the need for stronger investments in public health. But the best time to make those investments is before the next pandemic strikes. Healthy communities are ones where people and health systems are prepared for new threats, and where the underlying causes that lead to poor health leaving communities more vulnerable are addressed at the population level. Now is the time to prioritize sustained investment in public health for a healthier tomorrow.