2008 Community Health Services
System Expenditures Summary Report
Introduction
The following report summarizes 2008 expenditures of the Community Health
Services (CHS) System. This information is submitted by Minnesota’s local
health departments to the Minnesota Department of Health. Local health
departments report expenditures by funding source and area of public health
responsibility. The funding sources are: local tax levy, other federal funds,
Medicaid, other local funds, LPH Act state funds, other state funds, other fees,
Medicare, Title V funds, TANF funds, client fees, and private insurance. The
areas of public health responsibility are: assure health services, healthy
communities, environmental health, infrastructure, infectious disease, and
emergency preparedness. Complete explanations of the funding sources and areas
of public health responsibility can be found in Appendices A and B.
In 2008, there were 73 local public health reporting entities (referred to in this
report as local health departments) in Minnesota. Minnesota’s CHS System
consists of 53 Community Health Boards (CHBs). CHBs are allowed to decide
the jurisdictional level at which they will report their data. For example, a multicounty CHB could have each county in the CHB report as an individual county or
could choose to report collectively as one CHB. Of the 73 local health
departments included in this report: 28 are single-county CHBs, 10 are multicounty CHBs, 31 are single counties reporting separately within multi-county
CHBs, and 4 are city CHBs.
Per capita calculations are based on the 2007 population numbers from the State
Demographic Center.
The CHBs are split into geographic regions for analysis. Appendix C contains a
map of the regions.
The report is broken down into two sections:
• Statewide Expenditures Summary
• Regional Expenditures Comparisons
The appendices include:
A. Definitions of the Funding Sources
B. Areas of Public Health Responsibility
C. Map of the CHS System
2008 Community Health Services System Expenditures Summary Report
Page 1 of 18
July, 2009
Statewide Expenditures Summary
CHS System expenditures were $317 million ($60 per person) in 2008 (Figure 1). This
represents a $15 million or 5% increase in expenditures from 2007. Fifty-six local health
departments (LHDs) had increases in total expenditures from 2007. The remaining 17
LHDs had decreases. The single largest funding source was local tax levy, accounting for
almost one third (33%) of all expenditures (Figure 1). Other federal funds, which include
WIC and public health preparedness funds, accounted for 16% of expenditures. The LPH
Act state funds (formerly referred to as the CHS subsidy) accounted for 7% of all
expenditures.
Figure 1. Funding Sources of the CHS System
Funding Source
2008 Dollars (in millions)
2008 Percentage of Total
Local Tax Levy
$105.8
33%
Other Federal Funds
$50.2
16%
Medicaid
$41.5
13%
Other Fees
$29.7
9%
LPH Act State Funds
$20.8
7%
Other Local Funds
$18.6
6%
Other State Funds
$17.8
6%
Medicare
$12.1
4%
Federal TANF
$6.9
2%
Federal Title V
$6.2
2%
Private Insurance
$3.7
1%
Client Fees
$3.6
1%
Total
$317
----
Federal TANF expenditures increased by 47% ($2.2 million) due to an increase in federal
funds for the TANF program. Local tax levy expenditures increased by 7% ($7 million)
from 2007. Medicaid and Medicare also increased from 2007, 7% ($2.7 million) and 23%
($2.3 million) respectively. Client fees decreased by 20% ($900,000) but made up a very
2008 Community Health Services System Expenditures Summary Report
Page 2 of 18
July, 2009
small portion of overall expenditures. The LPH Act state funds decreased by 5% ($1
million).
Figure 2 Funding for the CHS System
(Aggregated by Major Funding Sources)
State Funds
12%
Federal Funds
20%
Locally Generated Funds
68%
Two-thirds (68%) of total funding for the CHS System came from locally-generated
funds, which include reimbursements and fees for services, local tax levy, and other local
funds (Figure 2). State funds accounted for 12% while federal funds accounted for 20%
of total funding.
2008 Community Health Services System Expenditures Summary Report
Page 3 of 18
July, 2009
Figure 3. LPH Act State Funds, Local Tax Levy, and Medicaid as a
Percentage of Total Expenditures (1983-2008)
40%
Percentage of Total Expenditures
35%
30%
25%
20%
15%
10%
5%
08
07
20
06
20
05
20
04
20
03
20
02
20
01
20
00
20
99
20
98
19
97
19
96
19
95
19
94
19
93
19
92
19
91
19
90
19
89
19
88
19
87
19
86
19
85
19
84
19
19
19
83
0%
Year
CHS Subsidy/LPH Act State Funds
Local Tax Levy
Medicaid
Figure 3 shows the trends of three funding sources as a percentage of total expenditures.
The LPH Act state funds have decreased as a percentage of total expenditures over time.
Since 2004 those funds have comprised 7% of total expenditures. The local tax levy, as
percentage of total expenditures, has generally fluctuated between 25% and 35%, with
one outlier in 2002. In 2008 Medicaid accounted for 13% of total expenditures. In 1983,
the first year it was tracked, it was 8% of total expenditures and has fluctuated between
13% and 19% over the past decade.
2008 Community Health Services System Expenditures Summary Report
Page 4 of 18
July, 2009
Figure 4. Flexible Funding* as a Percentage of Total Expenditures
(1979-2008)
*Flexible funding is the combination of local tax levy and
LPH Act state general funds.
40%
40%
41%
40%
35%
33%
33%
35%
38%
38%
37%
36%
26%
30%
36%
35%
35%
37%
33%
37%
41%
43%
43%
44%
47%
51%
48%
36%
40%
49%
52%
Percentage of Total Expenditures
50%
52%
60%
20%
10%
19
79
19
80
19
81
19
82
19
83
19
84
19
85
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
0%
Year
The LPH Act state funds and local tax levy are “flexible funding,” meaning that these
two funding sources are not associated with specific contractual requirements, categorical
grants, or reimbursements. Figure 4 shows the proportion of flexible funding has
decreased from 52% in 1972 to 40% in 2008. After dipping to a low of 26% of total
expenditures in 2002, flexible funding has been increasing and leveled off at 40% during
the past 3 years.
2008 Community Health Services System Expenditures Summary Report
Page 5 of 18
July, 2009
Figure 5. Comparison of Sources of Local Health Department Funding
Between Minnesota and the Nation*
35%
30%
33%
29%
Nation (2005)
Percent of Total
25%
Minnesota (2008)
23%
20% 20%
20%
15%
13%
12%
12%
10%
9%
10%
6%
7%
4%
5%
2%
0%
Local
Government
State Direct
Federal (Direct
& Passthrough)
Medicaid
Type of Funding
Medicare
Fees
Other
*2005 National Profile of Local Health Departments, National
Association of County and City Health Officials, July 2006.
Figure 5 compares funding for local health departments (LHDs) in Minnesota to the
findings of a national survey of local health departments conducted by the National
Association of County and City Health Officials (NACCHO) 1 in 2005. Minnesota
expenditures are similar to the national averages in the funding sources of federal and
Medicare funding but are somewhat different in all other funding areas. Local health
departments in Minnesota receive less state direct dollars than the national average but
more local government funds.
Figure 6 shows that 25 LHDs (34%) had total expenditures of less than $1.5 million and
45 LHDs (62%) had total expenditure of less than $2.5 million. The median total
expenditure was $1.8 million, an increase of $200,000 from 2007. Total expenditures
ranged from $240,416 to $73.8 million. The smallest one-third of LHDs accounted for
6% of total the CHS System expenditures. The largest LHD represented 23% of total
expenditures of the CHS System; the two largest LHDs represented 38%. The six LHDs
with the greatest total expenditures were in the metro region.
1
2005 National Profile of Local Health Departments, National Association of County and City Health
Officials, July 2006.
2008 Community Health Services System Expenditures Summary Report
Page 6 of 18
July, 2009
Figure 6. Total Expenditures by Local Health Departments
25
20
Number of Local Health Departments
20
17
15
13
10
8
7
5
5
2
1
0
< $500,000
$500,000 $1,499,999
$1,500,000 $2,499,999
$2,500,000 $3,499,999
$3,500,000 $4,499,999
$4,500,000 $5,499,999
$5,500,000 $6,499, 999
> $6,500,000
Total Expenditures
Figure 7. Per Capita Expenditures by Local Health Deapartment
25
21
20
Number of Total Local Health Departments
20
19
15
10
7
5
5
1
0
< $20
$20-$39
$40-$59
$60-$79
$80-$99
> $100
Per Capita Expenditures
2008 Community Health Services System Expenditures Summary Report
Page 7 of 18
July, 2009
Figure 7 shows per capita expenditures by LHDs. Twenty-one LHDs had per capita
expenditures of less than $40. Per capita expenditures by LHDs ranged from $13 to $210,
with a median per capita of $52. Five of the seven LHDs with expenditures greater than
$100 per capita provided home health services, hospice services, or both to smaller, more
rural populations.
Figure 8 shows the dollar amount and percentage of total expended in each area of public
health responsibility. Each area of public health responsibility was funded through a
different mix of funding sources. Brief funding summaries for each area of public health
responsibility are described below.
Figure 8. Expenditures by Area of Public Health Responsibility
Area of Public Health
Dollars
Percentage of Total
Responsibility
(in millions)
Spending
Assure Health Services
$133.1
42%
Healthy Communities
$85.3
27%
Environmental Health
$43.4
14%
Infrastructure
$26.7
8%
Infectious Disease
$17.9
6%
Emergency Preparedness
$10.6
3%
Total Spending
$317
----Assure Health Services
Expenditures in the area of health services were by far the largest, totaling $133.1
million, $6.4 million more than in 2007. Assure health services expenditures were
supported by local tax levy (36%) and Medicaid (24%). Eighteen percent ($24.3 million)
of spending was on home health and hospice services. It is important to note that one
local health department expended $50 million dollars in assure health services,
accounting for 38% of overall expenditures, 71% of all local tax levy dollars, and 27% of
the Medicaid dollars spent in the area of assure health services.
Healthy Communities
Over $85 million (27% of total expenditures) were expended in the area of healthy
communities, an increase of four million dollars from 2007. Over one quarter of healthy
communities expenditures ($22.9 million) were supported by other federal funds. All but
two LHDs used other federal funds to support these activities. Healthy communities
activities were funded by a wide range of sources including local tax levy (25%), LPH
Act state funds (10%), Medicaid (10%), other state funds (5%), and other local funds
(6%). Nearly all health departments (95%) used some LPH Act state funds to support
healthy communities.
Environmental Health
Environmental health expenditures increased slightly from $42.5 million in 2007 to $43.4
million in 2008. Other fees supported 56% ($24.4 million) of the environmental health
expenditures. Other funding sources included local tax levy (30%), other state funds
(6%), and other local funds (4%). It is important to note that one LHD represented 49%
of spending in this area, accounting for 77% of the other fees expended. Another LHD
2008 Community Health Services System Expenditures Summary Report
Page 8 of 18
July, 2009
represented 23% of spending, accounting for almost 60% of local tax levy expended.
Seven LHDs had no spending in the area of environmental health.
Infrastructure
Eight percent of total expenditures were in the area of infrastructure ($26.7 million), an
increase of about $1.5 million. Of the $26.7 million expended, most (67%) was funded by
local tax levy. Eighty-four percent of LHDs used local tax levy to fund infrastructure.
The remaining funding sources included LPH Act state funds (19%) and other local
sources (6%). Sixty-six of the 73 LHDs (90%) used LPH Act state funds for
infrastructure.
Infectious Disease
Six percent ($17.9 million) of total expenditures were in the area infectious disease, an
increase of 15% ($2.1 million) from 2007 due almost exclusively to one LHD’s increase
in infectious disease expenditures. Other federal funds supported 43% ($7.6 million) of
infectious disease spending. Other funding sources included local tax levy (26%), LPH
Act state funds (11%), and client fees (7%). It is important to note that one LHD
accounted for 41% of infectious disease spending and accounted for 88% of the other
federal funds in infectious disease.
Emergency Preparedness
Emergency preparedness expenditures were the least of the six areas of public health
responsibility, with $10.6 million or 4% of total expenditures. Emergency preparedness
expenditures decreased by 6% from 2007 to 2008 due to in part by a 36% decrease in
local tax levy funds. Almost 85% ($9 million) of the 2008 emergency preparedness
funding was from other federal funds. Federal preparedness and pandemic flu planning
dollars comprise the majority of other federal funds. The remaining funding came from
other local tax levy (11%) and state general funds (3%).
Regional Expenditures Comparisons
Figure 9 shows total and per capita expenditures by region. The west central region had
the highest per capita spending at $79 and the northeast region has the smallest at $37.
All but one region (northeast) had an increase in per capita expenditures.
Figure 9. Regional Expenditures and Per Capita
Total
Region
Per Capita
Expenditures
West Central
$
14,752,860
$
79
Metro
$
190,699,872
$
67
Southeast
$
31,594,077
$
65
Northwest
$
11,372,719
$
57
Southwest
$
12,518,556
$
56
South Central
$
15,414,436
$
53
Central
$
28,769,240
$
41
Northeast
$
11,793,348
$
37
$
316,915,108
$
60
Total
2008 Community Health Services System Expenditures Summary Report
Page 9 of 18
July, 2009
Metro
Northeast
Northwest
South
Central
Southeast
Southwest
West
Central
State Funds (LPH Act)
8%
6%
13%
9%
7%
5%
9%
8%
7%
Federal Title V
2%
2%
4%
3%
2%
2%
3%
2%
2%
Federal TANF
3%
2%
4%
2%
2%
2%
3%
2%
2%
Medicaid
12%
10%
14%
24%
14%
24%
13%
16%
13%
Medicare
10%
0%
7%
7%
10%
4%
7%
13%
4%
Private Insurance
1%
1%
1%
2%
6%
3%
1%
1%
1%
Local Tax
31%
40%
24%
9%
20%
25%
23%
20%
33%
Client Fees
2%
0%
1%
4%
2%
3%
2%
2%
1%
Other Fees
1%
14%
4%
0%
2%
3%
6%
5%
9%
Other Local Funds
5%
5%
3%
7%
10%
6%
9%
10%
6%
Other State Funds
8%
4%
6%
11%
10%
11%
6%
5%
6%
Other Federal Funds
18%
16%
18%
22%
15%
12%
19%
16%
16%
Figure 10 compares the funding sources of each region. Local tax levy as a percentage of
total expenditures ranged from 9% to 40%. The LPH Act state general funds accounted
for between 5% and 13% of total expenditures for a region.
2008 Community Health Services System Expenditures Summary Report
Page 10 of 18
July, 2009
CHS
System
Central
Figure 10. Regional Comparison of Funding Sources
Northeast
Northwest
South
Central
Southeast
Southwest
West
Central
CHS
System
Healthy
Communities
Infectious
Disease
Environmental
Health
Emergency
Preparedness
Assure Health
Services
Metro
Infrastructure
Central
Figure 11. Regional Expenditures by Area of Public Health Responsibility
12%
7%
16%
7%
5%
13%
8%
9%
8%
37%
22%
39%
29%
37%
33%
43%
29%
27%
5%
7%
4%
4%
3%
3%
6%
3%
6%
4%
20%
8%
1%
4%
6%
6%
3%
14%
5%
3%
4%
5%
3%
2%
4%
4%
3%
38%
42%
29%
56%
48%
43%
33%
53%
42%
Expenditures by area of public health responsibility for each region are shown in Figure
11. Expenditures in environmental health ranged from 1% to 20%. There is little
variation between regions in the areas of infectious disease and emergency preparedness,
both ranged between 2% and 7%. Assure health services had the highest percentage of
expenditures in all regions except for the northeast and southwest.
2008 Community Health Services System Expenditures Summary Report
Page 11 of 18
July, 2009
Appendix A:
Definitions of Funding Sources
2008 Community Health Services System Expenditures Summary Report
Page 12 of 18
July, 2009
Client Fees
Expenditures that had revenue received as a client fee (i.e., sliding fees for a health care
or MCH service) as their source.
LPH Act State Funds
Expenditures that had the state general funds portion of the Local Public Health Act as
their source.
Local Tax Levy
Expenditures that had revenue from local tax levies as their source.
Medicaid
(Title XIX of the Social Security Act) Expenditures that had revenue from Medicaid
reimbursements as their source. This includes Prepaid Medical Assistance Plans
(PMAPs), community based purchasing and community alternative care (CAC),
community alternatives for disabled individuals (CADI), development disabled (DD)
(formerly known as mental retardation or related conditions (MR/RC)), elderly (EW),
and traumatic brain injury (TBI) waivers. This does not include alternative care (AC)
which is reported in other state funds.
Medicare
(Title XVIII of the Social Security Act) Expenditures that had Medicare reimbursements
as their source. Also include revenue from Minnesota Health Senior Options (MSHO).
Other Federal Funds
Report expenditures of revenue as the Federal Government other than those specified
elsewhere in the glossary (i.e. Medicaid, Medicare, TANF, and Title V). This includes
dollars that come directly and as pass thru funds. Any funds with a Catalog of Federal
Domestic Assistance (CFDA) number are federal funds. Examples include WIC,
Veteran's Administration, Pandemic Flu Supplemental Funding, and Public Health
Preparedness. This does NOT include Medicaid, Medicare, Medicaid waivers, Title V,
and TANF funds. If a grant is funded by both state and federal sources (e.g., 30% state
funds and 70% federal funds) divide the amount appropriately between Other State Funds
and Other Federal Funds.
Other Fees (non-client)
Expenditures from revenue received as a fee for service, or for a license or permit.
Usually the charge has been set by statute, charter, ordinance, or board resolution.
Other Local Funds
Expenditures from other local funds including in-kind and contracts, grants or gifts from
local agencies such as schools, social service agencies, community action agencies,
hospitals, regional groups, non profits, corporations or foundations. Please confirm that
these funds do not originate from a federal source.
Other State Funds
Expenditures of dollars spent from state funds other than those specified including grants
and contracts from the Minnesota Department of Health and other state agencies that are
2008 Community Health Services System Expenditures Summary Report
Page 13 of 18
July, 2009
not "pass thru" dollars from the federal government. Funds with a CFDA number are
federal dollars. Examples of other state funding include alternative care and family
planning special project grants. Please confirm that these funds do not originate from a
federal source. If a grant is funded by both state and federal sources (e.g., 30% state funds
and 70% federal funds) divide the amount appropriately between other state funds and
other federal funds
Private Insurance
Expenditures that had reimbursements received from private insurance companies as their
source.
TANF (Federal)
Total of invoices sent to MDH for reimbursement for the period of January 1st to
December 31tst that had Federal TANF from the Local Public Health Act as their funding
source.
Title V (Federal)
Expenditures of dollars that had the federal Title V (MCH) portion of the Local Public
Health Act as their source.
2008 Community Health Services System Expenditures Summary Report
Page 14 of 18
July, 2009
Appendix B:
Areas of Public Health Responsibility
2008 Community Health Services System Expenditures Summary Report
Page 15 of 18
July, 2009
Areas of Public Health Responsibility
Assure an Adequate Local Public Health Infrastructure (Infrastructure)
This area of public health responsibility describes aspects of the public health
infrastructure that are essential to a well-functioning public health system – including
assessment, planning, and policy development. This includes those components of the
infrastructure that are required by law for community health boards. It also includes
activities that assure the diversity of public health services and prevents the deterioration
of the public health system.
Promote Healthy Communities and Healthy Behaviors (Healthy Communities)
This area of public health responsibility includes activities to promote positive health
behaviors and the prevention of adverse health behaviors – in all populations across the
lifespan in the areas of alcohol, arthritis, asthma, cancer, cardiovascular/stroke, diabetes,
health aging, HIV/AIDS, Infant, child, and adolescent growth and development, injury,
mental health, nutrition, oral/dental health, drug use, physical activity, pregnancy and
birth, STDs/STIs, tobacco, unintended pregnancies, and violence. It also includes
activities that enhance the overall health of communities.
Prevent the Spread of Infectious Disease (Infectious Disease)
This area of responsibility focuses on infectious diseases that are spread person to person,
as opposed to diseases that are initially transmitted through the environment (e.g.,
through food, water, vectors and/or animals). It also includes the public health
department activities to detect acute and communicable diseases, assure the reporting of
communicable diseases, prevent the transmission of disease (including immunizations),
and implement control measures during communicable disease outbreaks.
Protect Against Environmental Health Hazards (Environmental Health)
This area of responsibility includes aspects of the environment that pose risks to human
health (broadly defined as any risk emerging from the environment), but does not include
injuries. This area also summarizes activities that identify and mitigate environmental
risks, including foodborne and waterborne diseases and public health nuisances.
Prepare for and Respond to Disasters, and Assist Communities in Recovery
(Emergency Preparedness)
This area of responsibility includes activities that prepare public health to respond to
disasters and assist communities in responding to and recovering from disasters.
Assure the Quality and Accessibility of Health Services (Assure Health Services)
This area of responsibility includes activities to assess health care capacity and assure
access to health care. It also includes activities relate to the identification and reduction of
barriers to health services. It describes public health activities to fill health care gaps,
reduce barriers and link people to needed services.
2008 Community Health Services System Expenditures Summary Report
Page 16 of 18
July, 2009
Appendix C:
Map of Regions
2008 Community Health Services System Expenditures Summary Report
Page 17 of 18
July, 2009
Local Public Health Regions
Northwest
Kittson
Lake
of
the Woods
Roseau
Marshall
Koochiching
Beltrami
Pennington
St. Louis
Cook
Red Lake
Lake
Clearwater
Polk
Mahnomen
Norman
Itasca
Hubbard
Northeast
Cass
Becker
Clay
Aitkin
West
Central
Crow
Wing
Wadena
Wilkin
Carlton
Otter Tail
Mille
Lacs
Todd
Grant
Traverse
Pine
Kanabec
Morrison
Douglas
Central
Benton
Stevens
Pope
Stearns
Sherburne
Big
Stone
Swift
Lac
Qui
Parle
Washington
Meeker
Chippewa
Ramsey
Hennepin
McLeod Carver
Yellow Medicine
Renville
Scott
Sibley
Lincoln
Chisago
Anoka
Wright
Kandiyohi
Isanti
Lyon
Redwood
Southwest
Nicollet
Le Sueur
Dakota
Rice
Goodhue
Wabasha
Brown
Pipestone
Rock
Murray
Nobles
Cottonwood
Jackson
Watonwan Blue Earth
Martin
Faribault
Steele Dodge
Waseca
Metro
Freeborn
Olmsted
Mower
Fillmore
Southeast
Winona
Houston
South Central
2008 Community Health Services System Expenditures Summary Report
Page 18 of 18
July, 2009