The Use of Local Tax Dollars in Kentucky Local Health Departments to Sustain Programs From 2009-2013

This is a descriptive “case” study of public health finance in Kentucky, no data from other states were examined. The data used in this study were provided by the Kentucky Department for Public Health (KDPH). The data used in this study are longitudinal (2009-2013) and the core focus of this study is on: 1) changes in funding from the state to the 57-61 local health departments (single county and multi-county district departments) 2009-13, 2) changes in restricted and un-restricted fund reserves among local health departments, and 3) an examination of the local taxing districts and greater reliance on use of local tax dollars to fund mandated and non-mandated services at the local level. The financial data from the Kentucky Department for Public Health include fund balances, financial audits, and tax rates from 2009 – 2013. From an academic and intellectual history perspective, this study fits within the PHSSR (public health systems and services research) field of study, and more specifically, within the emergent substantive field of research on public health finance. This study utilized the conceptual/empirical framework of the County Health Rankings as an organizing mechanism. The County Health Rankings framework begins with “the end in mind.” The outcomes are population-health oriented in content and scope: 1) reductions in premature death and 2) improvements in quality of life measures such as the percentage of the population reporting excellent or good, as opposed to fair or poor physical and mental health days. Following the completion of this descriptive phase of the study, a more causal-oriented analysis will be implemented. Therefore, this study is designed to be descriptive in nature and more hypothesis generating than hypothesis testing or confirming. There has been a reduction from 2009-13 in Federal funding to the Commonwealth of Kentucky for public health. The overall percentage reduction is -11.1% ($42,909,657). There are four funding streams to KDPH, each of which had reductions from 2009 - 2013: 1) Federal 2) General Fund, 3) Restricted, and 4) Tobacco Master Settlement Funds. The most important finding is that the overall percentage of what Kentucky spends on public health from the Federal government has increased from 51% of the total in 2009 to 56% in 2013. The source of funding for public health flowing to local health departments from KDPH, either from the Federal level or through state-level funds, is also organized into four streams: 1) Federal pass through, 2) State General Fund, 3) Restricted, 4) Tobacco Master Tobacco Settlement funds. The overall reduction in these streams is -14.7% or $23,114,227). It is important to note that the percentage of dollars that are “Federal” in origin that are earmarked for local health departments from the “state” has increased from 2009 to 2013. Federal dollars are therefore being used to offset state funding reductions for public health. In Kentucky, state-level government spending represented by its biennial budget is limited to the amount of revenue available. The recent recession has produced limited degrees of freedom in Kentucky for funding new or for continuing funding of existing programs in public health, as well as a number of other areas. This, plus required, but un-anticipated, increases in mandated fringe benefits for local public health personnel has further restricted and constrained efforts by local health departments to deliver services. There are at least four types of services delivered by local health departments: 1) core mandated services, 2) non-mandated services, 3) community-driven services, and 4) foundational capabilities. Core mandated services are those that the local health department “must deliver,” based on Kentucky state law, although in most cases they are not fully funded. Unfortunately, in Kentucky some local health departments are struggling to pay for even these core mandated services. Therefore non-mandated services and community-driven services are often not being delivered. How can public health address community needs if local tax money is being used to backfill state mandated programs? A large proportion of the leading causes of death could be prevented by shifting policies, initiatives and programmatic efforts to address upstream factors. Smoking, poor diet and physical inactivity (specifically obesity) are causally related to each of the most prevalent leading causes of premature death and morbidity (i.e., cardiovascular diseases, cancers, strokes, COPD, diabetes). A good example of the lack of synchrony between the leading/actual causes of death and public health priorities can be found in the budget for the KDPH. In the entire KDPH budget there is no mention of lung cancer, 85-90% of which is caused by smoking. Kentucky ranks first among states in lung cancer mortality and second among states in smoking among adults according to the Kentucky Cancer Registry. Not only is there not a specific and robust KDPH initiative on lung cancer and smoking, the KDPH redirects dollars from the master tobacco settlement fund, designed to address tobacco use to childrens health programs such as funding for spina bifida without anencephaly and anencephaly ( in 2012 there were 1,460 cases and 859 cases respectively nationwide). Further, the KDPH has recently encouraged local health departments to focus on providing primary care. While local health departments in Kentucky have “clinics,” primary care is not population health. The rationale offered for encouraging local health departments to open primary care centers is based on the assumption that “local health departments can make money” from this kind of initiative. It could be argued persuasively that public health should not be focused on “making money” by providing clinical services. There are two painfully obvious questions that need to be raised concerning public health priorities in Kentucky as reflected in the 2014 KDPH budget. First Question: Why is there greater emphasis in the budget on infectious diseases and preparedness (epidemiology and health planning, 15% of the budget) than chronic diseases (prevention and quality improvement, 4% of the budget)? Second Question: Why is almost two-thirds of the KDPH budget focused on maternal and child health? These population groups do not account for a significant percentage of premature death and poor quality of life. Simply put, where is population health in the KDPH budget