Budget and priority setting in a time of
scarcity
JP Leider
Presenter Disclosure
JP Leider
The following personal financial relationships with
commercial interests relevant to this presentation
existed during the past 12 months:
No relationships to disclose
ASTHO and JHSPH project team members jointly worked on the conceptualization and
execution of this project
Thanks to the Johns Hopkins University Preparedness and Emergency Response Research
Center for funding part of this project. PERRC did not participate in the conceptualization
or execution of this project.
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Project team (in alphabetical order)
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Tom Burke, JHSPH
JP Leider, JHSPH
Beth Resnick, JHSPH
Katie Sellers, ASTHO
Thanks to:
• Nancy Kass, JHSPH
• Joseph Berger, JHU
• ASTHO staff
• State Health officials and their staff
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© 2011, Johns Hopkins University. All rights reserved.
Background
• State Health Agencies (SHAs) are critical players in
the public health system
• The Association of State and Territorial Health
Officials (ASTHO) reported that 76% of SHAs made
budget cuts during FY09 and 83% have experienced
job losses since the beginning of FY2009
• Cuts are frequently cumulative
• The National Association of County and City Health
Officials (NACCHO) reported that over 56% of LHDs
experienced funding cuts in 2010
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Study overview
• Stage one of a two-stage mixed methods,
exploratory project (Qual->Quan)
• 45 interviews were conducted in Spring 2011
• Transcribed, verified, and double-coded
• Six state health agencies
• Approximately seven interviews with executive and
division/bureau leadership in each agency
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Results: Top Resource Allocation Criteria
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Availability of funds
Delivery by others
Impact on locals and partners
Magnitude of problem or size
Mandatory match or services
Maximize dollars
Mission critical
Political interests
Prevention and protection
Seriousness of consequence
Results: Second-tier Criteria
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Capacity
Cost effectiveness
Unsustainable cuts
Emerging issues
Federal priorities
Impact on personnel
Means of correcting
Previous allocation and results
Strength of evidence
Target group
Results: Uncommon Criteria
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Aligned with strategic plan
Community interests
Equity promoting
Immediate benefit
Is service redundant
New or expanding program vs maintaining
Population based
Special interests
Results: Resource Allocation Criteria
activity agency budget community critical cuts determine direct dollars
essential
federal government governor grant
health impact
important issue
legislative legislature local mandated match mission money
just keep know
need
number partners people pressure prevention priority
program
responsibilities risk role
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protect provide
public
reductions
services show target time trying want years
Results: Hard choices
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Bureaucracy and politics
Causing harm
Cutting the core of Public Health
Educating policymakers and demonstrating value
Equally compelling services, not enough money
for both
• Geographic inequality
• Impact on individuals
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Results: Hard choices (continued)
• Respondents at all levels resoundingly
communicated that decisions that result in cutting
staff are the hardest
• Both division heads and executives identified ‘equally
compelling choices, not enough money’ as choices
that were difficult to cut
• Division heads (as compared to executives) said that
hard choices they encounter tend to be tied up in
bureaucracy or political influence
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Results: Tradeoffs
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Administration vs programs
Central vs Local
Current vs future need
Cuts vs human capital
Cutting broad vs deep
Efficiency vs need
Living within means vs unmet need
Medicaid vs Public Health
One group vs another
Political interests vs Public Health interests
Public vs Private sector delivery
Limitations, strengths & next steps
• Transferability
• Credibility
• Dependability
Next steps:
• Stage 2 national survey is in the field
• Combining with federal austerity scenarios to
examine likely pressures and potentially helpful best
practices
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Thank you!
• JP Leider
[email protected]
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