2011 Community Health Services System
Expenditures Summary Report
September 2012
Introduction
The following report summarizes 2011 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, Local Public Health (LPH) Act state
funds, other state funds, other fees, Medicare, Title V funds, Temporary Assistance for Needy Families (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 2011, there were 71 local public health reporting entities (referred to in this report as local health departments)
in Minnesota. Minnesota’s local public health system consists of 52 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 71 local health departments included in this report: 27 are single-county CHBs, 10 are multicounty CHBs, 30 are single counties reporting separately within multi-county CHBs, and 4 are city CHBs.
Per capita calculations are based on the 2011population estimates from the State Demographic Center.
The CHBs are split into geographic regions for analysis. Appendix C contains a map of the regions.
The report contains two sections:
Statewide Expenditures Summary ..............................................................................................................................2
Regional Expenditures Comparisons..........................................................................................................................8
The appendices include:
Appendix A: Definitions of Funding Sources ..........................................................................................................10
Appendix B: Areas of Public Health Responsibility ................................................................................................12
Appendix C: Map of Local Public Health Regions ..................................................................................................13
This report was made possible through the Preventive Health and Health Services Block Grant administered by
the Centers for Disease Control and Prevention.
September 2012
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2011 Community Health Services System Expenditures Summary Report
Statewide Expenditures Summary
CHS System expenditures were $315 million ($53.50 per person) in 2011, representing a $4.3 million or 1.3
percent decrease in expenditures from 2010. Overall, most (68 percent) LHDs had decreases in total expenditures
from 2010. The median decrease was 6 percent with a range of less than 1 percent to 22 percent. The 23 LHDs
with increases had increases that ranged from less than 1 percent to 17 percent with a median of 4.3 percent.
Table 1. Funding Sources of the CHS System, 2011
Funding Source
2011 Dollars (in millions)
2011 Percentage of Total
Local Tax Levy
$ 95.2
30.22 %
Other Federal Funds
$ 59.4
18.84 %
Medicaid
$ 30.9
9.80 %
Other State Funds
$ 29.5
9.38 %
Other Fees
$ 29.2
9.26 %
LPH Act State Funds
$ 20.9
6.63 %
Other Local Funds
$ 18.6
5.90 %
Medicare
$ 12.9
4.10 %
Federal TANF
$
6.8
2.16 %
Federal Title V
$
6.0
1.91 %
Client Fees
$
3.7
1.19 %
Private Insurance
$
1.9
0.60 %
Total
$ 315.0
----
The single largest funding source was local tax levy, accounting for 30 percent of all expenditures (Table 1). This
proportion increased from 29 percent in 2010. Other federal funds, which include WIC and public health
preparedness funds, accounted for 19 percent of expenditures. The LPH Act state funds accounted for 7 percent of
all expenditures and increased less than 1 percent from 2010. Other state funds decreased by $5.8 million or 16
percent from 2010.
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 (Figure 1). State funds accounted for 16 percent of total
expenditures and federal funds accounted for 37 percent. Together, state and federal funds represent over half of
LHD expenditures. This percentage has increased since 1977 (14 percent) as more state and federal funds are
available through grants and contracts.
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2011 Community Health Services System Expenditures Summary Report
Figure 1. 2011 Funding for the CHS System
Federal Funds
37%
Locally
Generated
Funds
47%
State Funds
16%
Figure 2 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. The local tax levy, as percentage of total
expenditures, has generally fluctuated between 25 percent and 35 percent, with one outlier in 2002. In 2011
Medicaid accounted for 10 percent of total expenditures. In 1983, the first year it was tracked, Medicaid
represented 8 percent of total expenditures and has fluctuated between 10 percent and 19 percent over the past
decade. Reimbursement rates and the number of LHDs providing home health care services affect the Medicaid
percentage.
Figure 2. LPH Act State Funds, Local Tax Levy, and Medical Assistance (Medicaid) as a Percentage of
Total Local Health Department Expenditures, 1983-2011
40%
35%
30%
25%
20%
15%
10%
5%
0%
LPH Act State Funds
September 2012
Local Tax Levy
Medicaid
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2011 Community Health Services System Expenditures Summary Report
Figure 3. Flexible Funding as a Percent of Total, 2011
60%
50%
40%
30%
20%
10%
0%
Flexible Funding as a percent of Total
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 3 shows the
proportion of flexible funding has decreased from 52 percent in 1972 to 37 percent in 2011. In 2002, flexible
funding dipped to a low of 26 percent of total expenditures. After climbing to 41 percent of total expenditures in
2005, flexible funding remained stable until a decline to 35 percent of total expenditures in 2009 and 2010.
Individual LHDs have a range of “flexible funding” from 4 percent to 74 percent with a median of 31 percent.
Figure 4. Comparison of Sources of Local Health Department Funding between Minnesota and the US, 2011 *
40%
36%
35%
29%
30%
25%
21%
20%
23% 23%
16%
13%
15%
10%
10%
10%
9%
7%
4% 3%
5%
1%
0%
Local
Government
State Direct
Federal
(Direct+Pass
through)
Medicaid
Minnesota (2011)
Medicare
Fees
Other
Nation (2010)
* 2010 National Profile of Local Health Departments, National Association of County and City Health Officials, August 2011
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2011 Community Health Services System Expenditures Summary Report
Figure 4 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) in 2010. In 2011,
Minnesota LHDs received less state direct dollars than the national average. Conversely, Minnesota LHDs
received proportionately more funding from local sources. ADD to Chart:*2010 National Profile of Local Health
Departments, National Association of County and City Health Officials, August 2011
Figure 5 shows that 23 LHDs (32 percent) had total expenditures of less than $1.5 million and 46 LHDs (65
percent) had total expenditures of less than $2.5 million. The median total expenditure was $1.9 million, a
decrease of $62,659 (3 percent) from the median for 2010. Total expenditures ranged from $235,757 to $71.7
million. The smallest one-third of LHDs accounted for 7 percent of total the CHS System expenditures. The
largest LHDs represented 11.3 percent of total expenditures of the CHS System; the two largest LHDs represented
39 percent of total expenditures. Of the eight LHDs spending over $6.5 million, one is a CHB composed of 5
counties, one contains the state’s third-largest city (Rochester) and six are in the metro region. This represents a
shift from 2010 when all the LHDs in the highest spending category were in the metro region.
Figure 5. Total Expenditures by Local Health Departments, 2011
>$6,500,000
8
$5,500,000 - $6,499,999
2
$4,500,000 - $5,499,999
1
$3,500,000 - $4,499,999
2
$2,500,000 - $3,499,999
Number of LHDs
12
$1,500,000 - $2,499,999
23
$500,000 - $1, 499,999
18
<$500,000
5
0
5
10
15
20
25
30
Figure 6. Per Capita Expenditures by Local Health Departments, 2011
>$100
6
$80-$99
7
$60-$79
15
$40-$59
$20-$39
24
<$20
1
0
September 2012
Number of LHDs
18
5
10
15
20
25
30
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2011 Community Health Services System Expenditures Summary Report
Figure 6 shows per capita expenditures by LHDs. Twenty-five LHDs had per capita expenditures of less than $40.
Per capita expenditures by LHDs ranged from $14 to $191, with a median per capita of $52; three dollars less
than in 2010. The six LHDs with expenditures greater than $100 per capita provided home health services,
hospice services, correctional health or a combination of these services to smaller, rural populations.
Table 2 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.
Table 2. Expenditures by Area of Public Health Responsibility, 2011
Area of Public Health
Responsibility
2011 Dollars
(in millions)
2011 Percentage of Total
Spending
Assure Health Services
$ 119.9
38 %
Healthy Communities
$ 106.7
34 %
Environmental Health
$ 36.4
12 %
Infrastructure
$ 24.1
8%
Infectious Disease
$ 17.4
6%
Emergency Preparedness
$ 10.4
3%
Total Spending
$ 315.0
-----
Assure Health Services
Expenditures in the area of health services were the largest, totaling $120.5 million. This is $5.5 million less than
in 2010, a decrease of 4.4 percent. Forty LHDs had decreases in assure health services. The median LHD
spending was $702,000 with a range from $11,000 to $42.4 million. Assure health services expenditures were
supported primarily by local tax levy (34 percent) and Medicaid (20 percent).
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 37 percent of assure
health services and 14 percent of all expenditures. Twelve percent ($14.1 million) of health services spending was
on home health care and hospice services. It is important to note that one LHD expended $42.4 million dollars in
assure health services, accounting for 35 percent of overall expenditures.
Healthy Communities
Over $107 million (33.8 percent of total expenditures) were expended in the area of healthy communities, an
increase of $3 million dollars (3 percent) from 2010. Even though there was a slight increase in overall spending,
thirty-two LHDs had decreases in healthy communities spending. The median LHD spending was $747,000 with
a range from $126,000 to $15 million. Thirty percent of healthy communities expenditures ($32 million) were
supported by other federal funds. Activities in healthy communities were funded by a wide range of sources
including other state funds (18 percent), local tax levy (21 percent), Medicaid (6 percent), LPH Act state funds (8
percent), and TANF funds (6 percent). All or most health departments also used some Federal Title V, Federal
TANF, Other State, Other Federal, and LPH Act state funds to support healthy communities.
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2011 Community Health Services System Expenditures Summary Report
Environmental Health
Environmental health expenditures increased by 5 percent ($1.7 million) from 2010 to $36.4 million in 2011.
Thirty-one LHDs had decreases in environmental health funding. Twenty- eight LHDs spent less than $5,000 on
environmental health, including 8 with no expenditures in 2011. The median LHD spending was $19,000 with a
range from $0 to $19.5 million. Other fees supported 64 percent ($23.3 million) of the environmental health
expenditures. Other funding sources included local tax levy (21 percent) and other state funds (7 percent). It is
important to note that two LHDs expended $26.4 million (73 percent) of spending in this area.
Infrastructure
Over seven percent of total expenditures were in the area of infrastructure, a slight increase of $680,000 (3
percent) over 2010. The median LHD spending was $185,000 with a range from 0 to $3.5 million. Of the $24
million expended, most (67 percent) was funded by local tax levy. Seventy-two percent of LHDs used local tax
levy to fund infrastructure, down from 82 percent in 2010. The remaining funding sources included LPH Act state
general funds (18 percent) and other local sources (9 percent). Fifty-seven of the 71 LHDs (80 percent) used LPH
Act state funds for infrastructure, down from 92 percent in 2010.
Infectious Disease
Less than 6 percent percent ($17.4 million) of total expenditures were in the area of infectious disease. This is a
decrease of $900,000 (5 percent) from 2010. The median LHD spending was $57,000 with a range of $0 to 7.7
million. Other federal funds supported 42 percent ($7.2 million) of infectious disease spending. Other funding
sources included local tax levy (32 percent), LPH Act state funds (12 percent), and client fees (5 percent). It is
important to note that two LHDs accounted for 56 percent of infectious disease spending.
Emergency Preparedness
Emergency preparedness expenditures were the least of the six areas of public health responsibility, with $10.4
million or 3.3 percent of total expenditures. Emergency preparedness expenditures decreased by 24 percent from
2010 to 2011. This decline reflects that preparedness spending was higher in 2009 and 2010 due to H1N1
response. The median LHD spending in 2011 was $57,800 with a range from $13,000 to $1.7 million. Seventythree percent ($7.6 million) of the emergency preparedness funding was from other federal funds and 21 percent
($2.1 million) was from the local tax levy.
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2011 Community Health Services System Expenditures Summary Report
Regional Expenditures Comparisons
Table 3 shows total and per capita expenditures by region. The west central region had the highest per capita
spending at $77.13 even though it decreased from $84 in 2010. The northeast region had the smallest at $38.85,
about the same as 2010. All regions had a decrease in total expenditures from 2010 except for the southeast
region, which had a slight increase of $137,846 (0.43 percent). Overall, total expenditures for the state decreased
by 1.3 percent from 2010.
Table 3. Regional Expenditures and Per Capita Expenditures, 2011
Region
Total Expenditures (in millions)
Per Capita Expenditures
West Central
$ 14.6
$ 77.13
Southeast
$ 32.0
$ 64.43
Southwest
$ 13.2
$ 59.86
South Central
$ 16.4
$ 56.24
Metro
$ 186.1
$ 54.29
Northwest
$ 10.8
$ 53.30
Central
$ 29.2
$ 39.87
Northeast
$ 12.7
$ 38.85
Total
$ 315.0
----
Percent of expenditures by area of public health responsibility for each region are shown in Table 4.
There is little variation between regions in the areas of infectious disease and emergency preparedness, with
ranges between 2 percent and 7 percent. The areas with the most variation (17 to 19 percentage points) across
regions are healthy communities, environmental health and health services. Expenditures on infrastructure vary
from 6 percent to 13 percent by region.
Assure health services had the highest percentage of expenditures in four regions (central, northeast, southeast,
and southwest). In the other four regions, health communities had the higher percent.
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2011 Community Health Services System Expenditures Summary Report
Table 4. Percent of Regional Expenditures by Area of Public Health Responsibility, 2011
Region
Infrastructure
Healthy
Communities
Central
10.59 %
42.94 %
4.77 %
2.76 %
4.42 %
34.51 %
Metro
5.76 %
28.54 %
6.73 %
17.54 %
3.21 %
38.22 %
Northeast
6.92 %
46.35 %
3.66 %
2.13 %
4.86 %
36.07 %
Northwest
12.91 %
33.98 %
3.62 %
0.13 %
4.05 %
45.31 %
7.00 %
40.66 %
2.81 %
3.70 %
3.44 %
42.39 %
Southeast
13.36 %
42.22 %
3.36 %
3.63 %
1.97 %
35.47 %
Southwest
8.37 %
47.65 %
5.30 %
4.55 %
3.96 %
30.18 %
West Central
10.24 %
34.51 %
2.96 %
2.13 %
2.57 %
47.60 %
CHS System
7.65 %
33.87 %
5.54 %
11.56 %
3.31 %
38.07 %
South Central
Infectious
Disease
Environmental
Health
Emergency
Preparedness
Assure Health
Services
Region
State Funds
(LPH Act)
Federal
Title V
Federal
TANF
Medical Asst.
(Medicaid)
Medicare
Private
Insurance
Local Tax
Client Funds
Other Fees
Other Local
Funds
Other State
Funds
Other Federal
Funds
Table 5. Regional Comparison of Funding Sources, 2011
Central
8%
2%
3%
11 %
8%
0%
29 %
1%
2%
4%
13 %
18 %
Metro
6%
2%
2%
7%
1%
1%
35 %
1%
14 %
6%
8%
19 %
Northeast
12 %
4%
4%
13 %
6%
1%
21 %
1%
1%
1%
15 %
20 %
Northwest
9%
3%
3%
13 %
6%
1%
12 %
9%
1%
8%
13 %
23 %
South Central
7%
2%
2%
14 %
14 %
0%
27 %
2%
4%
5%
9%
15 %
Southeast
5%
2%
2%
19 %
6%
0%
22 %
2%
3%
9%
12 %
19 %
Southwest
8%
2%
2%
13 %
4%
1%
24 %
2%
5%
7%
11 %
21 %
West Central
5%
2%
2%
15 %
23 %
1%
15 %
1%
3%
10 %
10 %
13 %
CHS System
7%
2%
2%
10 %
4%
1%
30 %
1%
9%
6%
9%
19 %
Table 5 compares the funding sources of each region. Local tax levy as a percentage of total expenditures ranged
from 12.4 percent to 35 percent. The LPH Act state general funds accounted for between 5 percent and 12 percent
of total expenditures for all regions.
September 2012
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2011 Community Health Services System Expenditures Summary Report
Appendix A: Definitions of Funding Sources
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.
Medical Assistance / 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 percent state funds and 70 percent 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.
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2011 Community Health Services System Expenditures Summary Report
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 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 percent state funds and 70 percent 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.
September 2012
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2011 Community Health Services System Expenditures Summary Report
Appendix B: 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.
September 2012
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2011 Community Health Services System Expenditures Summary Report
Appendix C: Map of Local Public Health Regions
September 2012
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