Ups and Downs of Local Health Departments

Regardless of budget cuts local health departments are still finding ways to continue providing quality care.


Despite staff and budget reductions, local health departments (LHDs) are finding ways to expand services in some areas, according to a survey by the National Association of County and City Health Officials (NACCHO). One-third of LHDs reported reducing services of at least 1 program area, such as immunization, diabetes screening, and high blood pressure screening. However, one-fourth said they were expanding population-based preventive programs for obesity, drug, alcohol, and tobacco.

The association has periodically surveyed LHDs since 2008 to assess the impact of the economic recession. In 2014, NACCHO renamed the survey “The Forces of Change” and expanded it to take in a wider range of factors. The 16-question online survey, distributed during January-February 2015, went to 948 LHDs in the U.S. (excluding Rhode Island and Hawaii, which have no LHDs), representing one-third of all LHDs. Of the 690 top executives who responded, 353 represented small, 271 medium, and 66 large LHDs.

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At the peak of budget cuts, in 2009, 45% reported budget decreases. Since then, about 1 in 4 LHDs is still reporting budget cuts compared with the previous year; 27% expect budget decreases to continue into the next year.

Since 2008, NACCHO says, 51,700 jobs have been lost. More than half the 3,400 lost in 2014 were due to attrition; the rest to layoffs. The number of lost jobs was “most marked” among large LHDs: Sixty-one percent of those reported at least 1 job lost, followed by 41% of medium and 26% of small LHDs.

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For many LHDs, “the cumulative effects of budget cuts and job losses” have not been reversed as the economy recovered. Some are trying creative workarounds, such as collaborations with primary care providers (PCPs). For example, 61% report actively encouraging PCPs to use evidence-based public health services, such as interventions to reduce asthma triggers.

However, < 10% of LHDs were actively engaged in new systems of care with PCPs, such as State Innovation Models (multipayer health care payment and service delivery models), patient-centered medical homes, or accountable care organizations (networks of health care providers voluntarily responsible for providing coordinated care). And < 70% are engaged in or exploring partnerships with nonprofit hospitals, which NACCHO says “might benefit multiple stakeholders and the community at large.”

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