Assessing the public health activity estimate from the national health expenditure accounts: Why public health expenditure definitions matter

The United States spends over $3 trillion on health and healthcare. Official estimates put governmental public health spending at less than 3% of all health spending nationally - $75.4 billion. However, even this relatively modest estimate may, in fact, be vastly overinflated. The project team engaged in manually recoding expenditure data used to create the national Public Health Activity estimate (PHAE). Teams of 2-3 researchers coded expenditure data based on a framework informed by the Foundational Public Health Services model and the Centers for Medicaid and Medicare Services definitions for public health spending. In 2013, Census data show that state governments spent approximately $63 billion on non-hospital health spending. Manual recoding suggests this figure, which is used in the construction of the national PHAE, includes about 40% on public health, 21% on Behavioral Health. 20% on Community Health Care, 8% on Disability-Related spending, 3% on Environmental Protection, and 8% on Other. These revised estimates are stable proportionately over the period data were available, 2000-2013. Thus, overall our analyses show the PHAE should be revised downward 50% or more. This has signfiicant implications for local, state, and federal policymakers when considering resource allocations for governmental public health.