Congress has poured tens of billions of dollars into state and local public health departments in response to the coronavirus pandemic, paying for masks, contact tracers and education campaigns to persuade people to get vaccinated.
Public health officials, used to juggling bare-bones budgets, worry the money will dry up as the pandemic recedes, continuing a boom-bust funding cycle that has plagued the U.S. public health system for decades. They fear they'll be back to scraping together money from a patchwork of sources to provide basic services to their communities — much like after the Sept. 11 attacks and the SARS and Ebola outbreaks. That could leave the nation where it was before COVID-19: unprepared for a health crisis.
"We need funds that we can depend on year after year," said Dr. Mysheika Roberts, the Columbus, Ohio, health commissioner.
When Roberts started in Columbus in 2006, an emergency preparedness grant paid for more than 20 staffers. By the time coronavirus hit, it paid for about 10. Relief money that came through last year helped the department staff up its COVID-19 response teams. While the funding has helped the city cope with the immediate crisis, Roberts wonders if history will repeat itself.
When the mosquito-borne Zika virus tore through South America in 2016, causing serious birth defects, members of Congress couldn't agree how, and how much, to spend in the U.S. for prevention efforts. The Centers for Disease Control and Prevention took money from its Ebola efforts, and from state and local health department funding, to pay for the initial Zika response. Congress eventually allocated $1.1 billion for Zika, but by then, mosquito season had passed in much of the U.S.
"Something happens, we throw a ton of money at it, and then in a year or two we go back to our shrunken budgets and we can't do the minimum things we have to do day in and day out, let alone be prepared for the next emergency," said Chrissie Juliano, executive director of the Big Cities Health Coalition, which represents leaders of more than two dozen public health departments.
Several lawmakers, led by Democratic U.S. Sen. Patty Murray of Washington, are looking to end the boom-bust cycle with legislation that would provide $4.5 billion annually in core public health funding. Health departments carry out essential government functions — such as managing water safety, issuing death certificates, tracking sexually transmitted diseases and preparing for infectious outbreaks.
Spending for state public health departments dropped by 16% per capita from 2010 to 2019, and spending for local health departments fell by 18%, KHN and The Associated Press found in a July investigation. At least 38,000 public health jobs were lost at the state and local level between the 2008 recession and 2019.
Compounding those losses, the pandemic has prompted an exodus of public health officials because of harassment, political pressure and exhaustion. A yearlong analysis by the AP and KHN found at least 248 leaders of state and local health departments resigned, retired or were fired between April 1, 2020, and March 31, 2021. Nearly 1 in 6 Americans lost a local public health leader during the pandemic. Experts say it's the largest exodus of public health leaders in American history.
Experts said the system needs dependable money to keep high-skill professionals, such as epidemiologists, and for technology upgrades that would help track outbreaks and get information to the public.
In Ohio, the computer system used to report COVID-19 cases to the state predates the invention of the iPhone. State officials had said for years they wanted to upgrade it, but they lacked the money and the political will. Ohio is working on a new system, but Roberts worries that, without a dependable budget, the state won't be able to keep that one up to date either.
"You're going to need to upgrade that," Roberts said. "And you're going to need dollars to support that."
In Washington, the public health director for Seattle and King County, Patty Hayes, said she is asked all the time why there isn't a central place to register for a vaccine appointment. The answer comes down to money: Years of underfunding left departments across the state with antiquated computer systems that were not up to the task when COVID-19 hit.
Hayes recalls a time when her department would conduct mass vaccination drills, but that system was dismantled when the money dried up after the specter of Sept. 11 faded. Roughly six years ago, an analysis found that her department was about $25 million short of what it needed annually for core public health work.
Public health officials in some areas may struggle to make the case for more stable funding because a large swath of the public has questioned — and often been openly hostile toward — the mask mandates and business restrictions that public health officials have imposed through the pandemic.
In Missouri, some county commissioners who were frustrated at public health restrictions withheld money from the departments.
In Knox County, Tennessee, the Board of Health was stripped of its powers in March and was given an advisory role.
"This is going to change the position of public health and what we can and cannot do across the country," said Dr. Martha Buchanan, the head of the county's health department.
A KHN and AP investigation in December found at least 24 states were crafting legislation that would limit or remove public health powers.
Back in Seattle, locally based companies have pitched in money and staff members for vaccine sites. Microsoft is hosting one location, while Starbucks offered customer service expertise to help design them. Hayes is grateful, but she wonders why a critical government function didn't have the resources it needed during a pandemic.
"They'll look back at this response to the pandemic in this country as a great example of a failure of a country to prioritize the health of its citizens, because it didn't commit to public health," she said. "That will be part of the story."