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Commentary: county government influence on health care safety-nets.

The study reported by Hillary Knepper demonstrates the commitment of counties to health care services and the perceived importance of county involvement in improving access and reducing disparities. The success of government involvement in public health care was recently demonstrated by Mays and Smith (2011). They demonstrated that a 10% increase in spending by local health departments between 1993 and 2005 was associated with a 6.9% reduction in infant mortality and a 3.2% fall in cardiovascular disease mortality.

Although almost 90% of counties do fund health care programs, levels of support have been limited and variable. Local public health spending in 2008 varied from $1 per capita to more than $200 per capita, and 35% of local health departments underwent funding cuts between 1993 and 2005 (Mays & Smith, 2011).

Many barriers to county involvement exist. Most commonly cited are the limited financial resources of counties to support a growing and seemingly unlimited craving for health care services. This is made more difficult by the counter-cyclical nature of the need, that is, the need is greatest (i.e., more uninsured and more illness) when the resources are most limited (i.e., during economic downturns with falling tax revenues, support of charities, and business support).

In addition, health care is not the only demander for more county resources. Adding health care resources may thus have substantial opportunity costs, that is, money added to health care may displace funds for, as an example, schools. As emphasized by Chernew and his associates (2003), a robust, growing economy can, at least in the short- or intermediate-term, absorb rising health care costs without displacing other needs; in a declining or in a slowly growing economy, however, any increase in any one cost necessarily displaces funds from others.

Other barriers likewise exist. The contestable role of government versus the market and the role of social systems versus personal responsibility play out at the county as well as at the national level. What is the responsibility--ethical and legal--of government, including county government, for those who "should have" personally taken steps to provide for themselves? Are these people "victims" or "sinners," that is, are they in need because of circumstances beyond their control or because of bad personal choices over which they did have control?

Other difficult questions remain. Should a county directly fund health care services or serve as a convener of other organizations to help meet the meet? Should a county fund private care or be a direct provider of services? How does a county interface and meld its services with those of community organizations and providers? Will expanded public services displace or crowd-out resources from market-based providers? And, what level of government--county, state, federal--is responsible for which services? In Tennessee, for example, most county health departments report to the state's Department of Health while those in the largest cities are locally funded and managed. As a local mayor once commented, the federal government downloads the problem to the state and the state downloads the problem to him, but he has no one to download the problem on to.

Although the health care burden is large, what is important for community leaders to recognize is that improving (or, at least, maintaining) the health of the community is an essential if not a mandatory requirement for economic recovery and growth (Mirvis & Bloom, 2008). A sick workforce is not a productive workforce. Sick children do not learn the skills to make them productive adults. Companies and investors do not move to places with unhealthy populations. Thus, health is an economic engine that makes health care part of the community's necessary infrastructure, along with roads, schools, and other publically supported services.


Mays, G. P., & Smith, S. A. (2011). Evidence links increases in public health spending to declines in preventable deaths. Health Affairs, 30 (8), 1585-1593.

Chernew, M. E., Hirth, R. A., & Cutler, D. M. (2003). Increased spending on health care: How much can the United States afford? Health Affairs, 22 (4), 15-25.

Mirvis, D. M., & Bloom, D. E. (2008). Population health and economic development in the United States. JAMA, 300, 93-95.


University of Tennessee, Knoxville

David Mirvis received his MD degree from the Albert Einstein College of Medicine of Yeshiva University, and subsequently trained in internal medicine and cardiology at the National Institutes of Health and at the University of Tennessee. He currently is Adjunct Professor in the Department of Public Health at the University of Tennessee, Knoxville. His research interests include health systems and health policy.
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Author:Mirvis, David
Publication:Journal of Health and Human Services Administration
Geographic Code:1USA
Date:Jun 22, 2012
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