health expenditures per person, about $251 was spent on public health by federal, state, and local governments.

National calculations of per capita spending mask a great deal of variation from one state to another and from one locality to another. The Trust for America’s Health (TFAH) estimates of spending on public health by state governments for 2009-2010 range from a low of $3.40 per capita in Nevada to a high of $171.30 per capita in Hawaii, with a median of $30.61 per capita (TFAH, 2011). At the local level, the median in 2005 was $29.57 per capita, and “spending in the lowest 20 percent of communities averaged only around $8 per person, while the top 20 percent spent an average of $102 per person” which is 12.75 times as high as the lowest quintile (TFAH, 2010b).

Cost-Sharing Among Levels of Government

The differing definitions and accounting methods complicate attempts to provide a detailed, accurate, and complete apples-to-apples breakdown of public health funding at different levels of government. For example, of the $77.2 billion that NHEA classifies as public health spending, 14.9 percent is attributed to the federal government and 85.1 percent to state and local governments—a large change from the 44 percent federal and 56 percent state and local share in 1970 (Catlin, 2011). It is unclear whether the 14.9 percent accurately reflects federal contributions to public health funding. Fiscal year 2010 NACCHO data show that combined federal funding (including funds passed through to states) accounts for about 23 percent of overall local public health agency revenues—a relatively small portion that the federal government contributes to local public health activities. NACCHO and NHEA appear to capture similar but not equivalent information: public health revenues for the former, and public health spending at all levels of government for the latter. Beitsch and colleagues estimated the total state and local share of governmental public health spending on the basis of data that they aggregated from ASTHO and NACCHO reports. They calculated that “spending of state and local public health agencies constituted 2.37 percent of all U.S. health spending for 2004” and 2.32 percent for 20056 (Beitsch et al., 2006, pp. 917-918). The 2004 and 2005 CMS Office of the Actuary data indicated that federal government public health activity accounted for 2.8 percent of total national health expenditure in both years. If one compares those figures with the state and local totals that Beitsch and colleagues calculated and assumes a level of concurrence in how the two sources defined public health activity, the state and local share for those years appears to be close to the current CMS figure: about 82 percent in


62005 data from the Office of the Actuary reported by Heffler et al. (2005).

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