摘要：Objectives. We examined public health system responses to economic shocks using longitudinal observations of public health activities implemented in US metropolitan areas from 1998 to 2012. Methods. The National Longitudinal Survey of Public Health Systems collected data on the implementation of 20 core public health activities in a nationally representative cohort of 280 metropolitan areas in 1998, 2006, and 2012. We used generalized estimating equations to estimate how local economic shocks relate to the scope of activities implemented in communities, the mix of organizations performing them, and perceptions of the effectiveness of activities. Results. Public health activities fell by nearly 5% in the average community between 2006 and 2012, with the bottom quintile of communities losing nearly 25% of their activities. Local public health delivery fell most sharply among communities experiencing the largest increases in unemployment and the largest reductions in governmental public health spending. Conclusions. Federal resources and private sector contributions failed to avert reductions in local public health protections during the recession. New financing mechanisms may be necessary to ensure equitable public health protections during economic downturns. The large and growing economic burden of preventable diseases and injuries in the United States raises important questions about the adequacy of the nation’s public health protections. These protections include activities to monitor community health status, investigate and control disease outbreaks, educate the public about health risks and prevention strategies, prepare for and respond to natural disasters and other large-scale health emergencies, and enforce laws and regulations designed to protect health such as those concerning tobacco exposure, food and water safety, and air quality. 1 Although most of the $2.8 trillion spent annually on health care in the United States is attributable to preventable health conditions, 2 less than 5% of these expenditures support public health strategies that are designed to prevent and control disease and injury. 3,4 Limited investments in public health have been implicated as contributing to the higher rates of preventable diseases and premature mortality experienced in the United States compared with other high-income countries. 5,6 To help address this problem, the Patient Protection and Affordable Care Act of 2010 (ACA) created the Prevention and Public Health Fund and authorized as much as $15 billion in new federal spending over 10 years to support public health activities implemented primarily at state and local levels. 7 Over time, however, federal policymakers have redirected large shares of fund resources to support other components of health reform implementation, such as the expanded training of primary care physicians, a temporary delay in scheduled Medicare physician payment cuts, and outreach and enrollment support for health insurance exchanges. 7,8 At the same time, the 2008 economic recession and subsequent slow pace of recovery have precipitated large and sustained reductions in state and local spending on public health activities. An estimated 55 000 public health workers were cut from state and local government workforces between 2008 and 2012. 9,10 Correspondingly, in 2011 the National Health Expenditure Accounts program recorded the first year-over-year reduction in total governmental public health spending since the federal government began tracking this spending category in 1980. 3 The expiration of federal stimulus spending, which helped offset state and local public health spending cuts in 2009 and 2010, contributed to the magnitude and timing of this reduction. Most recently, the federal budget sequester of 2013 has placed additional downward pressure on public health resources, with significant reductions in federal transfers to state and local governments for public health activities. Taken together, the ACA Prevention and Public Health Fund diversions, stimulus expirations, and budget sequestration may have blunted the ability of federal outlays to moderate recessionary contractions in state and local public health spending. These recent economic shocks raise the question of whether and how they have affected the implementation of public health protections in local communities. Government agencies may respond to funding reductions partly by improving operational efficiencies, such as by shifting to lower cost labor and technology or by enhancing the targeting and tailoring of programs to populations at greatest risk. Agencies may also reduce the scope and scale of public health activities they implement, causing a decline in the intensive margin of public health delivery as described in economic models of production. 11 As a third possible response, agencies may increase their reliance on the contributions of nongovernmental organizations in performing selected public health activities, thereby seeking to expand the extensive margin of public health delivery by bringing new resources into the production process. Indeed, several provisions of the ACA have created new incentives for the private provision of public health activities, such as enhanced community benefit requirements for tax-exempt nonprofit hospitals, minimum medical loss ratio regulations for health insurers that include credits for prevention and health promotion spending, and new federal tax incentives for employers to invest in wellness and health promotion programs. 7 In theory, these policies may allow governmental agencies to play larger roles in mobilizing and coordinating the public health activities of nongovernmental organizations instead of performing some activities directly, resulting in an expanded extensive margin. Whether economic shocks leave communities more vulnerable to disease and injury depends critically on changes to the intensive and extensive margins of public health delivery. To explore these possibilities, we analyzed longitudinal observations of public health activities implemented in US metropolitan areas during 1998–2012.
