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The Problem With Estimating Public Health Spending

Leider, Jonathon P. PhD

Journal of Public Health Management and Practice: March/April 2016 - Volume 22 - Issue 2 - p E1–E11
doi: 10.1097/PHH.0b013e3182941a7b
Original Articles

Accurate information on how much the United States spends on public health is critical. These estimates affect planning efforts; reflect the value society places on the public health enterprise; and allows for the demonstration of cost-effectiveness of programs, policies, and services aimed at increasing population health. Yet, at present, there are a limited number of sources of systematic public health finance data. Each of these sources is collected in different ways, for different reasons, and so yields strikingly different results. This article aims to compare and contrast all 4 current national public health finance data sets, including data compiled by Trust for America's Health, the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials (NACCHO), and the Census, which underlie the oft-cited National Health Expenditure Account estimates of public health activity. In FY2008, ASTHO estimates that state health agencies spent $24 billion ($94 per capita on average, median $79), while the Census estimated all state governmental agencies including state health agencies spent $60 billion on public health ($200 per capita on average, median $166). Census public health data suggest that local governments spent an average of $87 per capita (median $57), whereas NACCHO estimates that reporting LHDs spent $64 per capita on average (median $36) in FY2008. We conclude that these estimates differ because the various organizations collect data using different means, data definitions, and inclusion/exclusion criteria—most notably around whether to include spending by all agencies versus a state/local health department, and whether behavioral health, disability, and some clinical care spending are included in estimates. Alongside deeper analysis of presently underutilized Census administrative data, we see harmonization efforts and the creation of a standardized expenditure reporting system as a way to meaningfully systematize reporting of public health spending and revenue.

This article aims to compare and contrast all 4 current national public health finance data sets.

De Beaumont Foundation, Bethesda; and Office of Public Health Practice and Training, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

Correspondence: Jonathon P. Leider, PhD, 5272 River Rd, Suite 530, Bethesda, MD 20816 (

The author thanks Nancy Kass, Arthur Sensenig, Beth Resnick, and anonymous peer reviewers for their thoughtful comments and contributions that greatly improved the quality of this article.

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (

The author declares no conflicts of interest.

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.