The Trump administration's bungling of the federal government's response to the COVID-19 virus has drawn a lot of criticism, and rightly so. But it turns out that while things have surely gone from bad to insane under this administration, Washington has been failing local health departments since about 2008, as federal funding had been continually cut, leaving those departments with fewer resources than they need to deal with emergencies like pandemics.
That's certainly true locally. By all appearances, local health departments in the Bay Area are handing the virus as well as they can, but it's not possible to determine how much better their collective response might be if they had been getting the resources they needed from Washington over the past decade or so.
One reason it's hard to characterize the problem: The East Bay Express tried multiple times every day for nearly a week to speak with someone from the Alameda County, Contra Costa County, and San Francisco health departments. Only Contra Costa responded at all, to say there was no way they could spare even a few short minutes to inform the public on what it was up against. That might be an indication of how they feel about local media, but it is more likely an indication of their lack or resources.
The funding gap for health departments nationwide was made plain by the National Association of Counties when it issued a policy brief in February 2018, titled "Protect Funding for Core Local Public Health Services and Prevention Programs." In it, Blair Bryant, the association's associate legislative director for health, described the situation as dire: since 2008, she noted, local health departments had lost 56,000 jobs, or about 25 percent of their aggregate work force. She laid most of the blame on Congress, which began cutting funding for local health departments soon after the recession, and never stopped even after the economy recovered. The Prevention and Public Health Fund (PPHF), created in 2010 as part of the Affordable Care Act, is the main pipeline for federal funds designated for local health departments. The Centers for Disease Control, which manages the fund, describes it as "the nation's first mandatory funding stream dedicated to improving our nation's public health system." As of last year, it had transferred more than $7 billion to local health departments since its inception.
"Mandatory" it may be, but in her policy brief, Bryant noted that it, like the Affordable Care Act itself, has faced "multiple repeal attempts in Congress." So far, none have succeeded, but plenty of cuts have. The Budget Act of 2018 included cuts of $1.35 billion to be made over the following decade. In 2019, the fund received $804 million in appropriations, which is spread among about 2,800 local health departments.
"Further cutting PPHF funding, especially without increasing funding for local public health programs through regular appropriations, would negatively impact local public health departments already strained by having to respond to illness outbreaks," Bryant presciently noted in her brief.
In an interview last week, Bryant said that CDC funding in total "has been slashed consistently since 2003." Between those overall cuts and reductions in spending on local health departments, "there is definitely an impact" on how effective the response to COVID-19 can be, though we might not be able to fully assess that impact until the crisis is over. Local health departments, she said, get about 25 percent of their revenue from federal funds.
The state's contributions to public health were declining right along with federal funding. The San Francisco Chronicle reported on Monday that its analysis of spending by the California Department of Public Health showed that spending in total had fallen by 18 percent per capital since 2008. Worse, the paper reported, spending specifically designated for disaster relief, including pandemics, had dropped by 26 percent per capita. Last year, Gov. Gavin Newsom approved an increase of $40 million for spending to deal with infectious diseases, but the spending level was still below what it was 12 years ago.
On Monday, California lawmakers gave Gov. Gavin Newsom emergency authority to spend up to $1.1 billion for health-care needs and deploy other mitigating actions.
The biggest need at the moment is testing people for the virus. Testing is needed not only to know who should be quarantined, but also to determine where the hotspots are, and where resources are needed most. The Trump administration's astonishing sloth and false promises on this front have been widely reported: we're still doing a fraction of the testing that many other countries, including China, have done. Despite Trump's promise early this month that "a million" testing kits would be available within a week, the number actually deployed is still only in the tens of thousands.
That's about to change, as the Food and Drug Administration announced on Monday that it had approved kits from two manufacturers who have 2 million of them ready to deploy and more on the way. But the lack of resources at local health departments means they won't necessarily be deployed as quickly and efficiently as they should be. One reason whole swaths of the country are hunkering down — for example, Bay Area residents being asked on Monday to "shelter in place" for at least three weeks — is that we don't really know how deep the danger it really is for any given locality.
"We're getting a lot of announcements that more testing capacity is available, and then a lot of reports that it's not," said Joseph Greaves, executive director of the Alameda-Contra Costa Medical Association, in an interview last week. The confusion, he said, "is less than helpful." Greaves was quite hesitant to address the funding shortfalls for local health departments in recent years. He said people should be concentrating on the emergency at hand rather than on what is making it harder to address. Despite his reticence to discuss the issue, the association he heads has lobbied hard for increased funding for local health departments. He finally allowed that "when there's not adequate investment, it creates challenges."
The decrease in the overall work force tells just part of the story. Because health departments have less money, they often have trouble finding people with the right skills to handle, for example, disease outbreaks. A study conducted in 2017 by the National Association of County and City Health Officials found that it was difficult for many local health departments to lure advance-practice nurses and physicians in particular. "The primary reasons for these difficulties are that the pay is not competitive with other organizations, and often the geographical area is not desirable," said Andrea Grenadier, marketing and communication specialist for the association.
Another problem that might impact Bay Area health agencies in particular: funding for larger health departments has been cut more than it has for smaller ones. Those in areas with populations greater than 500,000 have seen funding fall by 20 percent on average since 2008, while departments in communities of less than 50,000 have seen only an 11 percent decrease, according to Grenadier. Disease pandemics, for obvious reasons, tend to hit larger, more densely populated areas harder than they hit smaller ones, which makes the disparity seem even more pronounced in situations like the current one.
Despite all the worries, the National Association of Counties believes that, as long as systems aren't absolutely overrun, local health departments should be able to handle the situation. "This is new territory," he said. But "with the right tools of mitigation, it's definitely doable."
The problem is, the systems might well be overrun, and the right tools might not be available.