Tuesday, March 17, 2020

American Austerity and the Pandemic

State and municipal public health departments are currently overwhelmed by outbreaks of COVID-19, thanks to budget cuts going back nearly two decades. After weeks of inaction, the Trump administration and Congress are now scrambling to bolster the public health response to coronavirus and mitigate the outbreak’s economic damage as businesses shut down and workers are sent home.

Public health departments nationwide have eliminated 50,000 positions since 2008, according to David Himmelstein, M.D., a professor of public health at the City University of New York at Hunter College. “Those missing 50,000 public health workers are why our response has been so inadequate.”

These were “front line” public health workers who are “trained to mobilize” and fight epidemics.

“They are the folks who actually go out and when someone is sick with an infectious disease … they track down the people who might be exposed and treat them in the case of treatable things like STDs or hepatitis, or isolate them in the case of COVID-19,” Himmelstein said.

Funding for public health has been declining for years. Health departments took a big hit during the Great Recession, when state governments cut spending to make up for losses in tax revenue. However, in many states this funding was never restored even as the economy recovered — along with positions formerly held by public health workers who combat the spread of disease. When adjusted for inflation, state public health spending was actually lower in 2016 and 2017 than it was in 2008 and 2009 when the recession first took hold, according to the Trust for America’s Health, a nonpartisan research and advocacy group. From 2015 to 2017, 31 states made cuts to their public health budgets, often because conservatives controlled their legislatures. Only 19 states maintained or increased their budgets during the same time period.
The CDC’s core budget has remained relatively flat for the last decade after steadily increasing from 1990 to 2010. Roughly 75 percent of the CDC’s budget is funnelled directly into programs operating at the state and local level. While the Affordable Care Act attempted to boost federal health spending at the local level through the section of the law known as the Prevention and Public Health Fund, the fund will receive nearly $12 billion less than the law intended by 2027, according to Trust for America’s Health. Except for one-time, short-term funding to contain the Zika and Ebola viruses, the CDC’s core emergency preparedness funding dropped from $940 million in 2002 to $667 million in 2017.
The U.S. government spends more than $1 trillion each year on health care, but  public health accounts for less than 3 percent of overall health expenditures. In countries such as Canada and the United Kingdom the proportion of spending on public health is roughly double that of the U.S. 

Himmelstein said, medical resources are “maldistributed.” For example, hospitals serving wealthier parts of the country may have plenty of ventilators and intensive care units for treating COVID-19 patients, while others are scrambling to respond with limited resources and protective equipment for staff. This creates massive holes in the public health response to outbreaks of disease and leaves some communities more vulnerable than others.
Himmelstein said hospitals in lower-income areas and communities of color are more likely to be underfunded and overburdened, because their patients tend to be covered by insurance that provides less profit for providers, if they are covered at all. Lower-income areas may not have enough health care providers to begin with, and these are often the same areas where politicians cut spending on public health.
“Instead of saying ‘let’s build hospitals where they are needed,’ we build them where they are profitable,” Himmelstein said.

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