2009 Community Health Services
System Expenditures Summary Report
Introduction
The following report summarizes 2009 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 2009, there were 73 local public health reporting entities (referred to in this
report as local health departments) in Minnesota. Minnesota’s local public health
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
multi-county 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 2008 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
2009 Community Health Services System Expenditures Summary Report
Page 1 of 17
August, 2010
Statewide Expenditures Summary
CHS System expenditures were $298 million ($56 per person) in 2009, representing a
$19 million or 6% decrease in expenditures from 2008. This decrease is heavy skewed by
one local health department (LHD) which sustained a $18.5 million cut. By removing this
LHD, there is a minimal decrease ($733,584) in expenditures. Overall, most (67%) LHDs
had increases in total expenditures from 2008. The median increase was 5% with a range
of less than one to 25%. Of the 24 LHDs with decreases, three had significant decreases
(> 30%) due to home healthcare programs no longer being provided or reported by the
LHDs. The remaining 21 LHDs decreases ranged from 1% to 25% with a median of 7%.
Figure 1. Funding Sources of the CHS System
2009 Dollars (in millions)
2009
Percentage
of Total
Local Tax Levy
$84.9
29%
Other Federal Funds
$52.9
18%
Medicaid
$38.8
13%
Other Fees
$28.2
9%
Other State Funds
$22.5
8%
LPH Act State Funds
$20.1
7%
Other Local Funds
$17.6
6%
Medicare
$12.5
4%
Federal TANF
$7.4
2%
Federal Title V
$5.9
2%
Client Fees
$4.6
2%
Private Insurance
$2.2
1%
Total
$298
----
Funding Source
The single largest funding source was local tax levy, accounting for 29% of all
expenditures (Figure 1). This was a decrease of 20% or $20.9 million. Although one
LHD made up a majority of the decrease, 35 LHDs received less local tax than in the
previous year. Other federal funds, which include WIC and public health preparedness
funds, accounted for 18% of expenditures. This slight increase is due to increased
preparedness funds. The LPH Act state funds accounted for 7% of all expenditures and
decreased 3%. Other State Funds increase $2.6 million or 26% from 2008; primarily due
to State Health Improvement Program (SHIP) funds.
A majority of the CHS System’s funding came from locally-generated funds, which
include reimbursements and fees for services, local tax levy, and other local funds
2009 Community Health Services System Expenditures Summary Report
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August, 2010
(Figure 2). State funds accounted for 14% while federal funds accounted for 22% of total
funding for a total of 36%. This percentage has increased since 1977 (14%) as more State
and Federal funds are available through grants and contracts.
Figure 2 Funding Source for the LPH System
State Funds
14%
Federal Funds
22%
Locally Generated Funds
64%
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 2009 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. Reimbursement rates and the number of LHDs
providing home health care services affect the Medicaid percentage.
2009 Community Health Services System Expenditures Summary Report
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August, 2010
Figure 3. LPH Act State Funds, Local Tax Levy, and Medicaid as a
Percentage of Total Expenditures (1983-2009)
40%
Percentage of Total Expenditures
35%
30%
25%
20%
15%
10%
5%
97
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
19
19
95
96
19
19
93
94
19
19
91
92
19
19
89
90
19
19
87
88
19
19
85
86
19
19
19
19
83
84
0%
Year
LPH Act State Funds
Local Tax Levy
Medicaid
Figure 4. Flexible Funding* as a Percentage of Total Expenditures
(1979-2009)
*Flexible funding is the combination of local tax levy and
LPH Act state general funds.
40%
35%
40%
40%
41%
35%
33%
35%
33%
38%
38%
37%
36%
26%
30%
36%
35%
35%
37%
33%
36%
37%
41%
43%
43%
48%
44%
49%
47%
51%
52%
40%
20%
10%
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
20
09
0%
19
Percentage of Total Expenditures
50%
52%
60%
Year
2009 Community Health Services System Expenditures Summary Report
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August, 2010
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 35% in 2009. 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 but in 2009 it fell to 35% primarily due to loss in local tax levy funds.
Individual LHDs have a range of “flexible funding” from 3% to 87% with a median of
28%.
Figure 5. Comparison of Sources of Local Health Department Funding
Between Minnesota and the Nation*
30%
29%
Minnesota (2009)
25%
Nation (2008)
25%
22%
20%
Percent of Total
20%
19%
14%
15%
13%
11%11%
10%
9%
10%
7%
4%
5%
5%
0%
Local
Government
State Direct
Federal
(Direct &
Pass-through)
Medicaid
Medicare
Fees
Other
*2008 National Profile of Local Health Departments, National
Association of County and City Health Officials, July 2009
Funding Type
Figure 5 compares funding for 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 2008. Minnesota expenditures are similar to the national
averages in the funding sources of Fees and Medicare funding but are different in all
other funding areas. In Minnesota, LHDs receive less state direct dollars than the national
average but more local government (local tax levy) and federal funds.
Figure 6 shows that 25 LHDs (34%) had total expenditures of less than $1.5 million and
47 LHDs (64%) had total expenditures of less than $2.5 million. The median total
expenditure was $1.8 million, a slight increase ($54,985) from 2008. Total expenditures
ranged from $194,548 to $55.3 million. The smallest one-third of LHDs accounted for
6% of total the CHS System expenditures. The largest LHD represented 18% of total
expenditures of the CHS System; the two largest LHDs represented 35% of total
expenditures. The six LHDs with the greatest total expenditures were all in the metro
region.
1
2008 National Profile of Local Health Departments, National Association of County and City Health
Officials, July 2009.
2009 Community Health Services System Expenditures Summary Report
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August, 2010
Figure 6. Total Expenditures by Local Heatlh Departments
25
22
Number of Local Health Departments
20
17
15
11
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 $5,499,999
> $6,500,000
Total Expenditures
Figure 7. Per Capita Expenditures by Local Health Department
25
21
21
Number of Local Health Departments
20
17
15
10
7
6
5
1
0
<$20
$20-$39
$40-$59
$60-$79
$80-$99
>$100
Per Capita Expenditures
2009 Community Health Services System Expenditures Summary Report
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August, 2010
Figure 7 shows per capita expenditures by LHDs. Twenty-two LHDs had per capita
expenditures of less than $40. Per capita expenditures by LHDs ranged from $9 to $216,
with a median per capita of $50; two dollars less than in 2008. Five of the seven LHDs
with expenditures greater than $100 per capita provided home health services, hospice
services, or both to smaller, 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
Percent Change from
Responsibility
(in millions) Total Spending
2008
Assure Health Services
$110.6
37%
-17%
Healthy Communities
$92.7
31%
9%
Environmental Health
$38.7
13%
- 11%
Infrastructure
$25.4
9%
-5%
Infectious Disease
$17.4
6%
-2%
Emergency Preparedness
$12.9
4%
22%
Total Spending
$298
-----6%
Assure Health Services
Expenditures in the area of health services were by far the largest, totaling $110.6
million, $22.6 million less than in 2008, a decrease of 17%. Forty-five LHDs had
decreases in assure health services, with one LHD accounting for a $22.6 million
decrease. The median LHD spending was $177,000 with a range from $79,000 to $27.6
million. Assure health services expenditures were supported by local tax levy (27%) and
Medicaid (26%). A significant part of assure health services includes providing services
through home health care, hospice, correctional health, and emergency medical services
programs. These services accounted for 46% of assure health services and 17% of all
expenditures. Eighteen percent ($24.3 million) of spending was on home health care and
hospice services. It is important to note that two LHDs expended $38.3 million dollars in
assure health services, accounting for 35% of overall expenditures, 62% of all local tax
levy dollars, and 29% of the Medicaid dollars spent in the area of assure health services.
Healthy Communities
Almost $93 million (31% of total expenditures) were expended in the area of healthy
communities, an increase of $7.4 million dollars (9%) from 2008. Forty-nine LHDs had
increases in healthy communities spending; these increases are due in part to the State
Health Improvement Program (SHIP). The median LHD spending was $616,000 with a
range from $76,000 to $14.3 million. Over one quarter of healthy communities
expenditures ($25 million) were supported by other federal funds. Activities in healthy
communities were funded by a wide range of sources including local tax levy (23%),
other state funds (11%), Medicaid (10%), LPH Act state funds (9%), and TANF funds
(8%). All or most health departments used some Federal Title V, Federal TANF, Other
State, Other Federal, and LPH Act state funds to support healthy communities.
Environmental Health
2009 Community Health Services System Expenditures Summary Report
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August, 2010
Environmental health expenditures decreased by 11% ($4.7 million) from 2008 to$38.7
million in 2009. Forty LHDs had decreases in environmental health funding while 20
LHDs had spending less than $5000 of which 9 had no spending. The median LHD
spending was $22,000 with a range from $0 to $20.6 million. Other fees supported 60%
($23.1 million) of the environmental health expenditures. Other funding sources included
local tax levy (25%), other state funds (6%), and other local funds (3%). It is important to
note that two LHDs represented 75% of spending in this area, accounting for 81% of the
other fees expended almost 70% of local tax levy expended.
Infrastructure
Nine percent of total expenditures were in the area of infrastructure, a decrease of $1.3
million (5%) caused by twenty-nine LHDs reducing spending in infrastructure. The
median LHD spending was $133,000 with a range from $1,000 to $3.7 million. Of the
$25.4 million expended, most (68%) was funded by local tax levy. Eighty-six percent of
LHDs used local tax levy to fund infrastructure. The remaining funding sources included
LPH Act state general funds (19%) and other local sources (8%). Sixty-six of the 73
LHDs (90%) used LPH Act state funds for infrastructure.
Infectious Disease
Six percent ($17.4 million) of total expenditures were in the area infectious disease, a
slight decrease of 2% from 2008. The median LHD spending was $60,000 with a range
from $2,270 to $7.7 million. Other federal funds supported 43% ($7.5 million) of
infectious disease spending. Other funding sources included local tax levy (28%), LPH
Act state funds (11%), and client fees (7%). It is important to note that two LHDs
accounted for 55% of infectious disease spending and accounted for 93% 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 $12.9 million or 4% of total expenditures. Emergency preparedness
expenditures increased by 11% from 2008 to 2009 due to in part to the H1N1 response.
The median LHD spending was $79,000 with a range from $17,000 to $1.6 million.
Almost 80% ($10.2 million) of the 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
and LPH Act state funds.
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.
2009 Community Health Services System Expenditures Summary Report
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August, 2010
Three regions had decreases in expenditures (metro, central, and west central) from 2008;
the remaining five regions had increases. Increases in spending in healthy communities
and emergency preparedness were seen in all regions. These increases were due to SHIP
funding and the H1N1 response. All regions had a decrease in funding in environmental
health and all but one had decreases in assure health services.
Figure 9. Regional Expenditures and Per Capita
Total
Region
Per Capita
Expenditures
West Central
$ 14,700,552
$
79
Southeast
$ 31,752,133
$
65
Metro
$ 170,631,855
$
59
Northwest
$ 11,573,226
$
58
Southwest
$ 12,721,292
$
58
South Central
$ 16,358,983
$
57
Central
$ 27,934,664
$
39
Northeast
$ 12,001,093
$
37
$ 297,673,798
$
56
Total
Percent of expenditures by area of public health responsibility for each region are shown
in Figure 10. 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 but three regions (central, northeast, and
southwest); in these regions health communities had the higher percent.
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 10. Percent of Regional Expenditures by Area of Public Health Responsibility
9%
8%
13%
10%
6%
13%
7%
9%
6%
40%
27%
44%
29%
39%
33%
44%
32%
31%
5%
7%
4%
4%
3%
3%
6%
3%
6%
3%
20%
2%
0%
4%
5%
5%
2%
13%
5%
4%
5%
5%
5%
3%
7%
5%
4%
39%
34%
31%
52%
44%
42%
31%
48%
37%
Figure 11. Regional Comparison of Funding Sources
2009 Community Health Services System Expenditures Summary Report
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August, 2010
Metro
Northeast
Northwest
South
Central
Southeast
Southwest
West
Central
8%
6%
13%
9%
7%
5%
9%
6%
7%
Federal Title V
2%
2%
4%
2%
2%
2%
2%
2%
2%
Federal TANF
3%
2%
4%
4%
2%
2%
3%
2%
2%
Medicaid
13%
11%
14%
15%
16%
21%
16%
16%
13%
Medicare
10%
0%
7%
8%
8%
5%
5%
23%
4%
Private Insurance
0%
0%
1%
2%
4%
1%
1%
1%
1%
Local Tax
27%
34%
24%
9%
22%
25%
20%
15%
29%
Client Fees
1%
1%
1%
12%
2%
3%
2%
2%
2%
Other Fees
1%
15%
1%
1%
3%
3%
6%
3%
9%
Other Local Funds
5%
6%
2%
5%
6%
6%
7%
11%
6%
Other State Funds
10%
5%
8%
11%
12%
13%
9%
7%
8%
Other Federal Funds
19%
18%
21%
22%
15%
14%
21%
13%
18%
Figure 11 compares the funding sources of each region. Local tax levy as a percentage of
total expenditures ranged from 9% to 34%. The LPH Act state general funds accounted
for between 5% and 13% of total expenditures for a region. All regions had increases in
Other Federal Funds due to funding for H1N1 while five regions had decreases in local
tax levy (central, metro, northeast, southwest, and west central).
2009 Community Health Services System Expenditures Summary Report
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August, 2010
CHS
System
Central
State Funds (LPH Act)
Appendix A:
Definitions of Funding Sources
2009 Community Health Services System Expenditures Summary Report
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August, 2010
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
2009 Community Health Services System Expenditures Summary Report
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August, 2010
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
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.
2009 Community Health Services System Expenditures Summary Report
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August, 2010
Appendix B:
Areas of Public Health Responsibility
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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.
2009 Community Health Services System Expenditures Summary Report
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Appendix C:
Map of Regions
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August, 2010
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
2009 Community Health Services System Expenditures Summary Report
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