Geographic variation in public health spending: Correlates and consequences

BACKGROUND: Geographic variation in the use of public health resources may contribute to gaps and inequities in population health, yet little is known about the extent and nature of this variation. This paper uses longitudinal data on local governmental public health agencies to examine how public health spending levels vary across communities and change over time. METHODS: A longitudinal cohort design is used to analyze variation and change in per capita public health spending levels within service areas of the nation's 2900 local public health agencies between 1993 and 2005. The National Association of County and City Health Officials (NACCHO) collected data on these agencies through census surveys fielded in 1993, 1996, and 2005. We linked these data with contemporaneous information on local population characteristics and health resources from other data sources. Multivariate regression models for panel data were used to estimate associations between local public health spending and an array of institutional characteristics, health resources, and population characteristics. RESULTS: Local public health spending reached $29.57 per capita for the median community in 2005 and increased less than 1 percent per year during the 1993-2005 period. The top 20 percent of communities had public health spending levels more than 13 times higher than communities in the lowest quintile, and most of this variation persisted after adjusting for differences in demographics and service mix. Local boards of health and decentralized state-local administrative structures were associated with higher spending levels and lower risks of spending reductions. Local public health spending was inversely associated with local-area medical care spending per capita. CONCLUSIONS: Increasing public health investments in communities with historically low levels of spending may provide an effective way of reducing geographic disparities in population health.