How Investing in Public Health Will Strengthen America’s Health

This report contains a correction.

Most of the gains in life expectancy achieved in the 20th century came not from medical progress. Rather, they resulted from public health advances such as cleaner air and water, improved sanitation and food safety, safer environments and thus fewer injuries, and vaccines to protect against infectious disease.¹

The World Health Organization defines public health as “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society.”² Public health systems, which address the needs of entire populations, are separate from medical or health care systems, which primarily address the needs of individual patients. In the United States, the public health system is dedicated to disease prevention and health promotion through federal, state, and local agencies and departments that track and predict emerging and persistent threats, respond to health risks and events, and promote health through education, intervention, and policymaking. It also identifies and addresses health disparities.

The challenge facing public health systems, both in the United States and around the world, is that public health interventions are successful only when misfortunes do not happen. When prevention works as intended, public health often goes unnoticed; but when prevention does not work, public health attracts attention.

This phenomenon has become all too evident amid the response to the COVID-19 pandemic. The challenges that the United States has faced in preventing the spread and reducing the impact of COVID-19 are in large part the result of inadequate public health preparedness and response. In fact, the United States has suffered more COVID-19 deaths overall than any other country in the world, with disproportionate impacts on people of color and low-income communities.³ On the other hand, countries that invested in public health preparedness before the pandemic have been able to respond more effectively to COVID-19.⁴ Still, infectious diseases respect no borders: U.S. domestic public health challenges must be married with strengthened capacity and coordination around the globe.

Chronic underinvestment has long challenged the U.S. public health system, and the lack of support and resources available during the pandemic, coupled with political polarization, has led many individuals to be unwilling to prioritize the evidence-based solutions needed to control the spread of COVID-19. The lack of public understanding of public health’s contribution to preventing disease, improving living conditions, and extending life expectancy may contribute to poor funding and policy decisions at the federal and state levels, while also undermining efforts to address critical social, economic, and environmental issues that contribute to health.⁵ This underinvestment puts the health, safety, and quality of life of both individual people and entire communities at risk.

This report considers the depth of the United States’ underinvestment in public health—and how better funding for public health can bolster the workforce, data, technology, and other infrastructure needed to prepare and respond to existing needs and future health threats, which are increasing in frequency and severity. It calls for investments that align with the benefits produced, from health improvement to financial savings to equity.

Specifically, the following recommendations can build a strong and responsive public health system:

For decades before and leading up to the emergence of COVID-19, U.S. public health infrastructure was both frail and fragmented due to chronic funding challenges. Public health funding is traditionally heavily siloed, with dollars dedicated to specific diseases or focus areas and allocated across several entities in the public health system.⁶ The responsibility to fund and conduct public health activities largely falls on state and local health departments, while the federal government provides supplementary funds through the U.S. Department of Agriculture (USDA); Health Resources and Services Administration (HRSA); Substance Abuse and Mental Health Services Administration; Environmental Protection Agency (EPA); Food and Drug Administration; Department of Homeland Security; and Centers for Disease Control and Prevention (CDC). The CDC is the main federal agency through which state and local funding for public health activities flows.⁷ Despite this, the CDC’s funding has declined over the years.⁸ Figure 1 shows a more than 8 percent decrease in CDC funding since 2010.

Figure 1

Historically, federal public health funding has been inconsistent and reactionary, with waves of increases following the 9/11 terrorist attacks and the passage of the Affordable Care Act but sharp cuts shortly after other events such as the passage of the Tax Cuts and Jobs Act of 2017 and the Great Recession.⁹ Indeed, under both the Obama and Trump administrations, federal funds meant to support public health programs and prevention efforts were reallocated to other non-public health priorities.¹⁰

Waves of public health funding often come after a public health emergency and are linked to specific diseases or issues, such as H1N1, Ebola, Zika, and now COVID-19.¹¹ Yet after the immediate danger from such threats subsides, funding is slashed.¹² In particular, the Public Health Emergency Preparedness (PHEP) cooperative agreement, which is the primary source of federal funds for state and local public health emergency preparedness and response, was a victim of that volatile funding and, despite temporary influxes during emergencies, has trended downward over the past 10 years. (see Figure 2)

Figure 2

Additionally, federal contributions to overall public health spending have long remained flat.¹³ As such, state and local funding sources must compensate for the increasing lack of federal funding, and many have struggled to make up the difference, leading to a patchwork of public health investment across the nation.¹⁴ Relying heavily on state and local funding for even minimum public health needs—for instance, investigating foodborne outbreaks, providing substance abuse services, and promoting maternal and child health—creates a system rife with inequities because investment, and therefore capabilities, varies significantly across the country. While each locality has a different mix of funding sources, local public health agencies rely in part on local revenue streams such as property taxes, which public school funding research has shown leads to racial and socioeconomic disparities.¹⁵ Considering these differences in how state budgets prioritize public health, the inconsistencies in local public health service offerings are unsurprising.¹⁶

A 2018 study found that in the United States, “only 51% of the population is served by a comprehensive public health system.”¹⁷ The Public Health National Center for Innovations has outlined eight foundational capabilities that each public health agency must have to provide the services in each of the five foundational areas of public health. (see Figure 3) These foundational capabilities reflect crosscutting skills and capacities needed for community health and well-being, and the foundational areas reflect the minimum level of public health services and protections needed to improve community health.

Figure 3

The boom-and-bust, disease-specific, and underfunded approach to public health makes it challenging to ensure that every community is served by a comprehensive public health system; it leaves little room for public health systems to protect health and well-being or to conduct the preparedness and surveillance efforts necessary to anticipate a health emergency. Indeed, the Government Accountability Office has found enduring deficiencies in the ability of the United States to prepare for, and respond to, a range of public health emergencies, including COVID-19 and other infectious diseases as well as extreme weather events such as hurricanes.¹⁸ Final authorizations of federal funding after the onset of a public health emergency have ranged from immediately after the emergency—in the case of Hurricane Katrina—to 235 days after, as seen in 2016 with the U.S. response to the Zika virus.¹⁹

The country must enact significant policy changes to provide adequate, flexible, and sustained funding for public health in order to protect against disease and disability as well as to respond quickly to a broad range of potential threats.

The weakened state of the public health system has had disastrous effects on the nation’s ability to respond to COVID-19²⁰—a reality, as public health experts warned, loomed well before 2020.²¹ Public health agencies lack the resources needed not only to handle the pandemic but also to address issues currently overshadowed by COVID-19 as well as to prepare for future emergencies.²² In the face of COVID-19, agencies temporarily abandoned core services such as HIV/AIDS education, smoking cessation programs, and maternal and child health promotion, among other services. As a result, state and local public health officials have reported a range of issues, including increases in drug overdoses, sexually transmitted diseases, cases of the flu, and intimate partner violence, as well as drops in reports of child abuse despite increasing concerns of risk among caseworkers.²³ Meanwhile, climate-related emergencies that pose public health challenges are occurring at alarming rates.²⁴

As a result, two years into the pandemic, public health professionals are incredibly strained after having to do more with fewer resources and workers.²⁵

A 2017 study of the public health workforce highlighted the system’s vulnerabilities pre-pandemic, finding that more than 56,000 local health department jobs had been eliminated since 2008 and that nearly half of the workforce planned to leave their job or organization by 2022 due to “inadequate pay,” “lack of support,” “lack of advancement,” or “workplace environment,” among other reasons.³¹ From 2008 to 2019, local public health department full-time staff decreased by 16 percent, while state agencies lost 10 percent of their staff from 2012 to 2019.³² Figure 4 shows a shrinking workforce ill-staffed to deal with even core public health services ahead of one of the worse public health emergencies in modern times.

Figure 4

In the public health sector, recovery from the pandemic has been slow.³³ In fact, workforce issues have become even more pronounced in the wake of COVID-19, with public health workers facing fatigue, hostility, and erosion of authority.³⁴ A January 2022 study of state and local public health staff revealed troubling findings: 56 percent of public health employees “report at least one symptom of post-traumatic stress disorder,” and others are generally struggling with their mental health.³⁵ Additionally, nearly 1 in 3 public health workers are “considering leaving their organization within the next year,” with 39 percent of those who intend to leave saying the pandemic increased the likelihood of their exit.³⁶ According to the study, the top two reasons for leaving were “pay” and “work overload/burnout.”³⁷

Under the intense politicization of the pandemic, many public health officials have reported facing unreasonable amounts of pressure, verbal abuse, and physical threats from the public and, in rare cases, other government officials.³⁸ Indeed, over the past two years, 41 percent of public executives have felt bullied, threatened, or harassed by people opposing health measures, while 56 percent have had their public health expertise challenged or undermined.³⁹ Their authority to implement key public health measures to combat the coronavirus has been weakened substantially: 32 states have enacted more than 100 new laws or other legal tools that either limit the power of public health officials altogether or ban certain public health interventions such as mask and vaccine mandates.⁴⁰ One Missouri public health official compared working under such restrictions to having one’s “hands tied in the middle of a boxing match.”⁴¹

Under these circumstances, the public health sector has become an inhospitable environment for even the most dedicated and passionate individuals. According to a Kaiser Health News-Associated Press report, more than 300 state or local public health officials either resigned, retired, or were fired from April 2020 to September 2021 likely due to pressures and restrictions on authority resulting from COVID-19. As a result, “1 in 5 Americans have lost a local health leader during the pandemic.”⁴²

On top of these challenges, compensation remains a major issue for workers in the public health field who have more advanced and specialized training. Salaries in many public health roles are significantly lower than those in private sector jobs while still largely requiring the same advanced education.⁴³ For example, entry-level salaries for workers with a graduate degree in public health are between $30,000 and $50,000, while the starting salaries of those with the same degree at consulting firms are typically higher.⁴⁴ Meanwhile, entry-level public health nurses make roughly $50,000, whereas a newly trained nurse could instead make more than $65,000, on average, in the private sector.⁴⁵

These salary gaps only add to the public health system’s workforce shortage. Even within the private sector, workers focused on public health can receive lower pay than others. For example, infectious disease specialists, the doctors who work alongside epidemiologists to diagnose and research pathogens, are the lowest-paid physicians in the United States.⁴⁶ The fact that workers must accept both lower pay and the additional stressors brought on by the pandemic makes retaining and recruiting a strong public health workforce difficult. Together, these issues have drained the public health workforce such that 80,000 to 100,000 more workers are currently needed to ensure that state and local departments can perform minimum public health services.⁴⁷

Effects on technology and data systems

Many public health departments and agencies are also severely lacking in modern technology and data systems to support services that help identify community risk and inform prevention activities, such as conducting real-time disease surveillance, tracking mortality trends, and monitoring safety and environmental conditions.⁴⁸ This also limits agencies’ ability to target interventions and coordinate cross-jurisdictional solutions to large-scale public health emergencies.⁴⁹ In the early days of the pandemic, not only did labs experience backlogs of more than 10 days to process COVID-19 test results, but also some state health departments were relying on paper-based and manual entry procedures to receive and report results.⁵⁰ Because the CDC relies on state data in monitoring and tracking outbreaks, these rudimentary data systems at the local and state level delayed and hampered the federal government’s ability to rapidly respond to and contain COVID-19 early on in the pandemic.⁵¹

The data problem in public health is multilayered. On the most basic level, there are simply not enough workers to properly process, interpret, and leverage the data.⁵² For example, informatics specialists that develop data tools, work processes, and interfaces necessary for public health work only make up 1 percent of health department roles;⁵³ this means that other public health staff must fill the gaps in agency needs.⁵⁴ Meanwhile, inconsistencies in recording key demographic information such as race and ethnicity hinder the ability to track disparities in order to inform response strategies and resource allocation.⁵⁵ Another major issue with public health data systems is the lack of interoperability.⁵⁶ Historically, data systems have not communicated with one another in ways that facilitate timely data exchange.⁵⁷ These failures exist across settings, geographic regions, and government levels.

To fully understand the state of the U.S. population’s health both within and outside of an emergency, medical systems, nursing homes, jails, and other congregate settings must have data systems that feed into local or state public health data systems. Public health departments must also be able to share data across localities and states as people move around. Specifically, local, state, and federal public health agencies must have robust data-sharing capabilities that facilitate the development of coordinated responses to widespread threats.

Even within the same department, interoperability can be a challenge based on function. During the pandemic, for instance, many states’ systems meant for tracking COVID-19 test results could not communicate with systems used for case management.⁵⁸ And as the threat of COVID-19 increased, many departments relied on manual data entry and cleaning processes to overcome these shortcomings, which often added to data errors and inconsistencies.⁵⁹ Even the best data systems were ill-equipped and strained under the weight of the massive amount of data it takes to monitor a pandemic.⁶⁰

The failures of public health data systems reflect the consistent lack of funding in public health. Even when funding has been directed toward public health, it has rarely been used specifically for data system improvement.⁶¹ The lack of direct investment into data infrastructure has hindered health departments’ ability to effectively carry out their core public health functions and projects, which often rely on certain data capabilities.⁶² Before the pandemic, the last influx of public health funding for data modernization came from the 2010 Affordable Care Act.⁶³ Thanks to new funding from the Coronavirus Aid, Relief, and Economic Security (CARES) Act and American Rescue Plan Act (ARPA), there has been improvement from those early pandemic days when the weaknesses of public health data systems were exposed. But the work is not done, and without additional funding, this progress will be short-lived. Public health officials at all government levels still report feeling less than prepared to handle the data needs of future emergencies.⁶⁴

While the pandemic has helped raise public awareness about the importance of public health,⁶⁵ misinformation and the politicization of COVID-19 have shaken Americans’ trust in the system. Indeed, a study from the Robert Wood Johnson Foundation and Harvard T.H. Chan School of Public Health found that less than half of the public reports having trust in public health agencies—and only 52 percent trust the CDC, while 70 percent trust health care workers.⁶⁶ Despite this, the overwhelming majority of Americans support funding increases to improve public health and believe that public health agencies are necessary for improving the nation’s health.⁶⁷ These findings highlight the real need to reassure the public of the competency of the public health system, in conjunction with increased investments and the creation of safeguards to ensure that public agencies are free of political interference.⁶⁸

In the absence of such actions, uptake of public health strategies and interventions will suffer—as illustrated by COVID-19 mitigation efforts. In 2020, researchers published an evidence-based model in Frontiers in Public Health that can help build and maintain public trust in public health officials, particularly during emergencies such as a pandemic.⁶⁹ Key tenets of this model were transparency, development of protocols and procedures, credibility, proactivity, collaboration, prioritization of the public, and education.⁷⁰

As with other public health emergencies, the COVID-19 pandemic brought on a wave of renewed funding at all levels of government. In 2020, Congress approved more than $300 billion in supplemental funding for federal public health agencies and the Public Health and Social Services Emergency Fund (PHSSEF) to respond to the coronavirus pandemic—including $500 million for public health data modernization through the CARES Act.⁷¹ Meanwhile, ARPA, which was signed into law in March 2021, provided nearly $93 billion in additional funding for public health activities, including vaccine education and distribution; data modernization, testing, and contract tracing; bolstering the Strategic National Stockpile, a repository of therapeutics, vaccines, and medical supplies and equipment ready for rapid distribution;⁷² and workforce development.⁷³ Of note, the Infrastructure Investment and Jobs Act, signed into law on November 15, 2021, made important investments in public health, even though it did not necessarily fund public health systems directly.⁷⁴ Some of these include $63 billion for water infrastructure, $21 billion for clean-up of environmental hazards, and $65 billion for power grid and clean energy improvements.⁷⁵

In addition, the House-passed reconciliation package would provide $10 billion over five years for “core public health infrastructure” and other public health activities.⁷⁶ While these investments are helpful and necessary to mitigate the impacts of COVID-19, more and longer-term support is needed to bolster foundational services and preparedness capabilities within the system and move beyond public health’s history of one-time crisis funding.

The appropriations process is also an opportunity to infuse more sustained funding into public health. The fiscal year (FY) 21 congressional appropriations included a number of provisions that support public health, including funding to strengthen lab capacity, enhance data modernization, and support workforce development.⁷⁷ Then, the FY 22 congressional appropriations built on this progress by making notable increases to federal public health agencies, compared with 2021 spending: a $582 million increase for the CDC, $200 million of which is directed to state and local infrastructure needs; a $325 million increase for the Office of the Assistant Secretary for Preparedness and Response (ASPR), $140 million of which goes to the Strategic National Stockpile; $148 million for the Biomedical Advanced Research and Development Authority (BARDA); and a $33 million increase for other public health efforts.⁷⁸

These are important steps away from one-time, crisis funding. At this stage in the pandemic, however, legislators appear less willing to invest in immediate pandemic recovery and mitigation strategies, let alone long-standing public health infrastructure. The White House has indicated that without further investments, further funding for COVID-19 efforts such as testing, vaccine distribution, and therapeutic procurement is not available, and it recently requested $22.5 billion from Congress.⁷⁹ This lack of funding is alarming, specifically how it impacts the uninsured.⁸⁰ Yet some legislators have been hesitant to invest more, claiming unused prior allocations and a lack of transparency around how funds are being spent.⁸¹

These issues point to perpetual challenges in funding public health: 1) it is not always easy to see the fruit of public health investments quickly; and 2) public health needs long-term sustained funding. It makes little sense to expect states and localities to rely on temporary funding to address long-term structural needs exacerbated by the pandemic. In particular, states and localities cannot hire staff if that staff cannot be maintained without continued funding.

Without timely action, progress in the public health system made from supplemental investments during the pandemic is at risk of erosion. Federal legislators should therefore focus on ensuring sufficient and consistent funding for public health, while also supporting pandemic emergency response efforts, which would support the Biden administration’s goals as well as calls from public health experts.⁸² A panel convened by the Public Health Leadership Forum found that $4.5 billion in new and permanent annual funding is needed to ensure equitable and sustained foundational public health services for all.⁸³ This comes down to an investment of $32 per person. Current national investments, however, amount to only $19 per person.

In 2020, life expectancy in other industrialized countries surpassed that of the United States by nearly five years.⁸⁴ The United States’ struggle to control COVID-19 while experiencing the world’s largest death toll added to a trend already in motion: the declining health of Americans.⁸⁵ Indeed, new academic analysis estimates that in 2021 U.S. life expectancy continued to decline, despite the development and distribution of effective COVID-19 vaccines.⁸⁶ Conversely, many of the United States’ peer countries saw their life expectancy rebound in 2021 after dropping in 2020.⁸⁷ Excess deaths among the working-age population are also on the rise.⁸⁸

Research makes clear that public health interventions improve health and quality of life exponentially.

Improved health outcomes

Moderate increases in public health spending have been linked to as much as a 7 percent decrease in mortality rates.⁸⁹ Studies have found that even a $10 per capita increase in local public health spending is associated with reduced overall mortality and a greater share of the population reporting being in “good,” “very good,” or “excellent” health.⁹⁰ Likewise, reductions in low birth weight, foodborne illnesses, rates of sexually transmitted diseases, and more have been linked directly to spending on public health interventions.⁹¹ In fact, one study in California found that every $1 invested in public health yields up to $88 in improved health status and benefits to society,⁹² proving the adage that an ounce of prevention equals a pound in cure.

Reduced health care costs

Investments in public health also have important implications for the health care system. In 2019, the United States spent roughly $3.8 trillion on health, but less than 3 percent of that was spent on public health specifically⁹³—a decline from the 3.2 percent spent on public health in 2000.

More recently, spending on health in the United States was $4.1 trillion in 2020 and is projected to rise to $6.2 trillion by 2028.⁹⁴ Despite spending more on health care than peer nations, however, Americans are not any healthier.⁹⁵ Population health in the United States continues to decline, while health care costs are rising and the vast majority of health care spending is used to treat conditions that could have been prevented.⁹⁶

Yet public health services are designed to do just that: prevent disease and injury before medical intervention is necessary. State-level analyses have shown that increases in public health spending reduce Medicare utilization, especially in areas with high poverty and uninsurance rates as well as areas with fewer health professionals.⁹⁷ Other estimates show that for every $1 invested in public health interventions focused on reducing common chronic conditions such as diabetes and cardiovascular disease, at least $5 in health spending is saved.⁹⁸ Likewise, spending more on social services than on health care has also been shown to produce better health outcomes,⁹⁹ supporting the idea that public health, and its focus on social determinants, requires investment to reach its goal of improved health.

For a concrete example of how the public health system works to protect individuals and communities and to promote health and well-being, see Figure 5 below, which shows how public health helps a parent, Jamie, and a child, Shay, in their everyday lives.

Figure 5

Public health interventions that help Jamie and Shay include:

Advancements in economic justice and equity

Investing in public health infrastructure would not only improve health and reduce costs but also advance economic justice and equity.

State and local public health workers are largely women (77 percent). In fact, women’s enrollment in public health degree programs outweighs that of men.¹¹⁴ Yet research shows that female-dominated occupations tend to have lower pay than male-dominated occupations, indicating a devaluation of work done by women.¹¹⁵ Given this fact, it should come as no surprise that gender disparities in pay are still persistent in the public health sector, especially among leadership positions.¹¹⁶ Men are also overrepresented in executive roles.¹¹⁷ These pay disparities and the lack of proportional representation at the very top put women in public health—and, subsequently, the whole field, given that they are the majority of workers—at a disadvantage.

In addition, the public health workforce is racially diverse: More than 40 percent of workers are nonwhite, and Black people have higher representation in public health than in the overall state and local government workforce.¹¹⁸

The demographic makeup of the workforce shows that public health can be a viable career option for women, people of color, and those living at the intersection of those identities. Therefore, economic equity can be advanced by improving wages, building education and training pathways into the profession, and providing opportunities for career advancement, thereby ensuring people with marginalized identities have access to competitive wages and opportunities for career growth.

The workforce shortages exacerbated by the pandemic are likely also to be compounded by an aging workforce: The median age for state and local public health workers is 48, while all other government workers have a median age of 45.¹¹⁹ In a 2017 survey, nearly a quarter of the public health workforce responded that they planned to retire by 2022.¹²⁰ Investing in public health now presents an opportunity not only to strengthen the number of public health workers but also to bring those workers in at early stages of their careers.

Public health improves health and quality of life while effectively reducing health disparities.¹²¹ By targeting interventions for low-income communities and communities of color, public health can help level the playing field of health and well-being. Additionally, because these communities tend to be underresourced, investments and workforce building efforts should target these communities first to advance health equity.

The increasing frequency and severity of public health threats makes investment and preparedness all the more urgent. The COVID-19 pandemic is but one example of the vast impact that a public health emergency can have on society. The increasingly common and severe impacts of the climate crisis pose yet another significant threat to health and safety—one that the current U.S. public health infrastructure cannot sufficiently manage.¹²² Indeed, the United States has battled a record-number of climate-related disasters over the past two years. In 2021 alone, the country experienced 20 different climate-related disasters, totaling $145 billion in damages and nearly 700 related deaths.¹²³

While the gaps in the current public health system leave everyone at risk, marginalized communities ultimately end up paying the highest price for this failure. For example, low-income areas and communities of color tend to be more vulnerable to severe weather events and more likely to be exposed to the environmental harms linked to accelerating climate change, such as pollution from the combustion and refining of fossil fuels, all while having fewer resources to recover.¹²⁴

Notably, a strong public health system is also key to ensuring national security. The 9/11 attacks highlighted public health’s critical role in responding to security threats, and after the attack, billions of dollars in federal funding were invested in state and local public health departments.¹²⁵ Emerging infectious diseases and environmental dangers that overwhelm the health system, weaken the economy, and even put the health and safety of key public health officials and military forces at risk threaten national security. Unfortunately, these threats are becoming increasingly more frequent.¹²⁶ The U.S. National Intelligence Council has recognized the rising threat of infectious disease to political and economic stability:¹²⁷ In 2000, for example, HIV/AIDS was deemed a national security threat given its ability to destabilize governments and economies and significantly increase death rates.¹²⁸ Ebola offers another example: The infectious disease posed such a threat such that the Obama administration incorporated a pandemic response team into the National Security Council; however, the Trump administration disbanded the team in 2018, a year before the first case of COVID-19 was discovered.¹²⁹

The COVID-19 pandemic has reinforced the connection between public health systems and national security. According to CNA, pandemics pose national security threats and embolden violent extremist organizations.¹³⁰ For example, COVID-19 has been used to undermine state authority. In particular, vaccine misinformation promotes public distrust, which has adversely affected the goal of reaching herd immunity and has therefore prolonged the COVID-19 pandemic and further threatened national security.¹³¹

These developments illustrate why ensuring the systems that detect, surveil, and report these diseases must be part of the country’s strategy to remain safe and secure.¹³² Beyond this, the growing threat of bioterrorism, such as the anthrax attacks of 2001, puts the nation’s security at risk and requires a robust public health response.¹³³

Furthermore, military resources and personnel are often called to support response efforts after public health emergencies—including extreme weather events—while backfilling local and regional public health and health care resources.¹³⁴ Therefore, the number of recruits who meet standards of military readiness is negatively affected as the overall health of Americans declines, further emphasizing the connection between national security and public health.¹³⁵

Public health emergencies are inevitable. Yet how the country invests in the system that manages them affects resiliency and the scope of harm that results. Both the human and economic costs of COVID-19 have already far exceeded those of 9/11, even without accounting for the long-term effects of the pandemic that are not yet known. Indeed, estimates place the cost of the 9/11 attacks between $2 trillion and $3.3 trillion,¹³⁶ while a 2020 study found that COVID-19 would cost the United States an estimated $16 trillion.¹³⁷ Yet that projection was under the assumption that the pandemic would end by late 2021. It is now 2022, and the pandemic continues to rage on, with multiple surges that have led to significant disability and loss of life.

Yet the country has historically dedicated far more resources to defense priorities than the public health system.¹³⁸ The United States does not hesitate to spend hundreds of billions of dollars each year to defend against conventional military threats or to fund a comprehensive nuclear deterrent. It is time to apply these risk-mitigation approaches to the public health issues that pose massive and urgent risks and that have much larger effects on American and global life expectancy. Funding levels for public health infrastructure and interventions must align with the benefit produced by investing—and the risk of not taking action.

COVID-19 has exposed the weakened state of the U.S. public health infrastructure and the need for stable, sustained funding to better address existing health threats and prepare for future emergencies. Investments must be made in strengthening the public health infrastructure, including bolstering the public health workforce; developing robust, modern, and interoperable data systems; and communicating clearly about the essential role of the public health system.

It is vital that the United States prioritize its public health system in order to strengthen the nation’s health and economic security. In November 2021, the Federal Reserve stated that the COVID-19 pandemic remained one of the largest threats to the financial system, noting that the “path of the economy continues to depend on the course of the virus.”¹³⁹ But the lessons learned from COVID-19 can also be leveraged to improve the public health system going forward.

Funding

The federal government and states must prioritize proper funding for public health in their policy decisions. Specifically, funding should be both stable and flexible in order to allow the public health system to adapt to immediate threats and long-standing local needs.

Prioritize stable, sustained public health system investments

At the beginning of 2022, many states had a budget surplus as a result of the rebound in tax revenue and federal pandemic aid from the CARES Act and ARPA.¹⁴⁰ According to data from the National Association of State Chief Budget Officers, state revenues rose steeply in FY 2021, increasing by an estimated 12.8 percent.¹⁴¹ The Infrastructure Investment and Jobs Act also provides additional investment opportunities that can be directed toward public health.

States can use ARPA funding in a variety of ways to support public health. As of November 2021, 30 states had spent ARPA funds on health-related services, including public health interventions. Eighteen states, meanwhile, had dedicated funding to water and sewer projects, such as drinking and wastewater maintenance and improvement.¹⁴² Other states are investing in broadband: Virginia, for example, appropriated $8 million to the state Department of Health to address connectivity and infrastructure issues at local health departments.¹⁴³

Several states are also using ARPA funds to build lab and testing capacity, improve data systems, and develop workforce supports:¹⁴⁴

• Nevada dedicated a portion of its public health emergency funding to operational needs and “expenses relating to establishing and enhancing public health data systems.”
• North Dakota allocated $15 million of its funds to building a public health laboratory.
• West Virginia allocated $49.9 million to its Department of Health and Human Resources for “COVID epidemiology and lab capacity for prevention and control, for vaccinations and testing supplies, and the Hospital Preparedness Program & public emergency preparedness.”
• Wisconsin dedicated $58.4 million to “local and tribal health departments to continue their work responding to the COVID-19 pandemic and build a strong recovery. Potential uses for the funding include: measures to stop the spread of COVID-19 such as testing, contact tracing, and vaccination programs; staffing for public health and safety; enhancing public health programs through improvements like technology infrastructure or data analysis; and addressing disparities in health outcomes.”

Replace siloed, disease-specific funding with comprehensive approaches to shoring up public health infrastructure

CDC funding, and the funding that flows from the CDC to state and local health departments, needs to be sustained and disease-agnostic in order to address gaps in capacity and detect and respond to emerging threats while meeting the existing demands of addressing infectious and chronic diseases and environmental hazards. In particular, health departments need funding to upgrade data systems; meet national quality standards; conduct performance improvement activities; increase communication, collaboration, and public health education campaigns; and meet changing conditions and needs.

More than 200 organizations have urged Congress to make a significant long-term investment in federal, state, local, tribal, and territorial public health infrastructure by adding $4.5 billion in annual funding to pay for essential activities such as disease surveillance, epidemiology, laboratory capacity, and all-hazards preparedness and response, as well as policy development and support, communications, community partnership development, and organizational competencies.¹⁴⁵

The bipartisan PREVENT Pandemics Act—sponsored by Sens. Patty Murray (D-WA) and Richard Burr (R-NC)—aims to strengthen the nation’s public health and medical preparedness and response systems in the wake of the COVID-19 pandemic. Funding would support public health and medical preparedness and response coordination; strengthen public health communication and health security; modernize biosurveillance capabilities and infectious disease data collection; improve recruitment and retention of the front-line public health workforce; and support research and accountability, among other provisions.¹⁴⁶ Additionally, the White House FY 23 budget proposal includes $10 billion for disease surveillance and forecasting, vaccination programs, data modernization, and research on the long-term effects of COVID-19—a $2.8 billion increase from 2021 allocations.¹⁴⁷ Yet funding remains insufficient; even supplemental funding for the most immediate COVID-19 response and recovery needs is currently being held up in Congress.¹⁴⁸

Preparedness

Given the increasing effects of climate change and emerging infectious diseases, the public health system must be prepared to respond to a wide range of health threats rapidly. This requires improvements in the surveillance and lab systems that monitor developing threats.

Upgrade and expand disease surveillance systems and lab capacity to identify unmet needs and emerging health threats

Improving testing and response capacity—including by expanding the number of state, local, federal, and other labs that participate in the Laboratory Response Network—would assist public health systems in responding quickly to biological and chemical terrorism, emerging infectious diseases, and other public health emergencies.¹⁴⁹ For example, the state of Michigan is using $220 million of its ARPA funds to build a new public health laboratory.¹⁵⁰

In addition to lab capacity, policymakers should fund improved data and predictive modeling on the health impacts of climate change. The Climate Change Health Protection and Promotion Act would mandate and provide funding for federal agencies to track environmental and infectious disease data and engage in forecasting and modeling. It would also provide technical support to state and local health departments, helping them develop climate preparedness plans and conduct community outreach.¹⁵¹

In addition, Congress must appropriate funds to strengthen adaptation interventions and their implementation, as well as to ensure that every state health department can prepare for climate change and track their progress through local-level monitoring. The CDC’s Climate and Health program, for example, through its Climate-Ready States and Cities Initiative, provides funding and technical assistance to states and localities seeking to improve their resiliency to climate change.¹⁵² Additional funding for this program would allow more communities to improve their resilience to climate change.¹⁵³

Data from public health laboratories are a mostly untapped resource for identifying health threats, including climate change and its health implications—for instance, the impact of air and water quality changes on illness and death—as well as increasing death rates stemming from COVID-19. The California Department of Public Health’s Environmental Health Laboratory, for its part, is assessing the impact of wildfire smoke on firefighters and residents, the spread of mosquitoes and ticks and its effect on vector-borne disease, and the presence of cyanotoxin in drinking water.¹⁵⁴

Wastewater surveillance is one promising infectious disease surveillance tool that can help scientists track how viruses evolve and mutate. This information can inform public health decisions, and in the case of COVID-19, it can inform the location of testing and vaccination sites as well as the distribution of resources to areas of need. The CDC is supporting states and localities in developing wastewater treatment surveillance programs and has initiated the National Wastewater Surveillance System to collect water samples from hundreds of wastewater treatment sites across the country.¹⁵⁵

Looking ahead, the United States should fund research to investigate the full range of viral families that threaten humans, with the goal of developing the diagnostics, vaccines, and therapeutics—and rapidly scalable manufacturing capacity—required for the next crisis. The Biden administration has committed to building capacity to develop and produce effective vaccines to protect the U.S. population within 130 days of a new biological threat before using surge production capacity on global needs. This ambitious goal will require substantial additional funding but could save countless lives.

Data

Public health requires modernized data systems that both communicate with other data systems and include sufficiently detailed and actionable information. This ensures that accurate data is available in rapid response efforts and can help determine equitable resource allocation.

Improve and standardize public health data collection efforts, including by capturing data on vulnerable communities

Data reported by broad racial and ethnic categories often mask disparities among subgroups. Yet unfortunately, there is a lack of detailed demographic characteristics—such as race, ethnicity, disability status, sexual orientation, and gender identity—in public health data.¹⁵⁶ Collecting more disaggregated data would help public health experts understand the nuances in the lived experiences of these subgroups. This understanding could then guide policymakers in targeting resources and interventions to the communities disproportionately affected by health threats, reducing health disparities and improving health outcomes.

In response to the challenges posed by COVID-19, states have made efforts to improve the granularity of their data collection. For example, North Carolina’s COVID-19 vaccination management system has a mandatory data entry field for patients’ race and ethnicity. By training providers and offering incentives to ensure consistent collection of data, North Carolina has received race and ethnicity data for 94 percent of COVID-19 vaccinations, supporting the effective allocation of resources to communities in need.¹⁵⁷

Invest in modern public health data capabilities that are flexible, dynamic, and interoperable

Timely and accurate data are essential to quickly identifying and responding to new threats and trends. Public health authorities need the ability to gather and analyze timely testing and monitoring data in order to convince leaders to take necessary preventive steps both domestically and internationally. Unfortunately, during the COVID-19 pandemic, the federal government was left to rely on data from foreign countries with more sophisticated public health monitoring systems in order to determine U.S. policy; testing, disease surveillance, and data management systems require modernization to fill this gap.¹⁵⁸ This will, in turn, require large investments to institutionalize improved public health systems—for example, by supporting regular genome sequencing of unknown respiratory diseases at home and abroad in order to detect new pathogens early and feeding that data into a global early warning system and database.

During public health emergencies, it is vital to aggregate real-time actionable data across both public and private settings and systems. State, local, and federal public health agencies need detailed, patient-level data quickly—typically within 24 hours—so they can better understand the populations affected by and the burden of diseases, conduct case investigations, and implement proper prevention and control measures. Initial case notifications are largely lab-based; however, basic demographic information does not typically flow from the ordering electronic health record (EHR) to the laboratory information system. Data elements necessary to help initiate a case investigation are missing when the labs report their results to public health agencies.

Additionally, federal agencies such as the CDC lack the legal authority to standardize and coordinate data-sharing within and across localities—which complicates their ability to access key local data, such as hospital capacity, without relying on piecemeal data agreements.¹⁵⁹ This hinders public health’s ability to respond in real time. Past CDC directors have likened this to the risk of “flying blind as health threats emerge.”¹⁶⁰

Public health must be modernized to solve interoperability issues so that seamless data-sharing between public health agencies and health care providers can be achieved.¹⁶¹ Michigan, for instance, is improving interconnectivity by allocating $115 million in health information technology systems, including its Michigan Care Improvement Registry, Disease Surveillance System, and Health Information Network.¹⁶²

The combined $1 billion in funding for public health data modernization—$500 million provided through the CARES Act and $500 million provided through ARPA—has catalyzed efforts to create modern, interoperable, and real-time public health data and surveillance systems.¹⁶³ This funding went to the CDC’s Data Modernization Initiative (DMI), which focuses on enhancing the ability of public health data systems to track and predict health threats. In addition to providing funds directly to public health agencies for data improvement, the DMI’s objectives include developing data standards to ensure cohesion and interoperability of data systems throughout the nation.¹⁶⁴ Among other objectives, the DMI is focused on leveraging new data sources and partnerships to support public health efforts, as well as on strengthening the critical and specialized workforce needed to work with public health data. Currently, only about 1 percent of health department roles specialize in data science and informatics.¹⁶⁵

Likewise, the CDC’s newly created Center for Forecasting and Outbreak Analytics, funded through ARPA, will improve the government’s ability to forecast and model emerging health threats, expand collaboration by increasing capacity for data-sharing and interoperability, and support policymakers by communicating forecasts to inform decisions.¹⁶⁶

While these investments have facilitated improvements over the past two years, current systems are still far from sufficient, and ongoing funding beyond APRA will be needed to ensure continued, consistent development. Health departments need access to affordable, standardized software and data, as robust data systems allow public health departments to be more efficient so that workers can dedicate time to other needs.¹⁶⁷ If the country does not invest in scalable approaches based on modern web standards, public health will continue to suffer from lagging and incomplete data.

Workforce

More workers are needed to build a robust and responsive public health system. Therefore, it is necessary to provide additional pathways for entry into the field, prioritizing workers from underrepresented communities. Moreover, further support—such as loan repayment and wellness initiatives—is needed to retain current workers while securing avenues for surge capacity before the next public health emergency.

Build a diverse and culturally competent workforce with training in strategic and systems thinking, data science, communication, and policy evaluation

The Biden administration invested $7.4 billion of ARPA funds in recruiting and hiring public health workers to respond to the COVID-19 pandemic and prepare for future public health threats. This funding will assist state and local public health departments in hiring staff to respond to the pandemic, including efforts related to vaccine outreach and administration as well as coronavirus testing. For example, HRSA is using nearly $48 million of ARPA funding to expand the public health workforce in rural and tribal communities, focusing specifically on roles such as community health support and health information technology.¹⁶⁸

In response to recommendations of the COVID-19 Health Equity Task Force, the Biden administration also is investing in building a more diverse and sustainable public health workforce. New investments support diversity, equity, and inclusion by raising awareness and interest among underrepresented groups, expanding recruitment for community health workers and other paraprofessionals, and creating pipeline programs in underserved communities.¹⁶⁹

Among other provisions, the American Rescue Plan included almost $300 million for the Association of Public Health Laboratories to provide fellowships and internships to support the public health laboratory workforce. The investment also provides funding for the creation of a Public Health AmeriCorps and a new CDC grant program.¹⁷⁰

There is also opportunity to invest in expanding apprenticeship pathways that train public health workers, often through union organizations. Several successful programs already exist for community health workers.¹⁷²

Efforts in California, for instance, are seeking to expand the pool of nurses in congregate settings through apprenticeship.¹⁷³ The U.S. Department of Labor (DOL) is already prioritizing expansion of registered apprenticeships across all sectors, with a $113 million investment in its “Apprenticeship Building America” program.¹⁷⁴ Additionally, the DOL’s “Good Jobs” initiative seeks to improve job quality and support the unions that often train and advocate for workers.¹⁷⁵

Capitalizing on the benefits of unions and making training programs more accessible is key to addressing workforce issues for workers in less specialized roles, such as community health workers and contact tracers. Moreover, it enhances these job roles’ competitiveness with the private sector, thus drawing in workers. Strategic cross-agency collaboration can be leveraged to ensure that public health roles are included in these efforts at the DOL and that more pathways are created to build up the public health workforce.

Provide incentives for public health service, such as loan repayment, bonus payments, pay equity, and opportunities for job growth

Through loan repayment programs, states repay or facilitate the repayment of student loans for qualifying health care providers. The National Health Service Corps’ (NHSC) Loan Repayment Program, for example, supports physicians specializing in primary care, dental care, and behavioral or mental health care in rural communities. A public health loan repayment program, as proposed in the Public Health Workforce Loan Repayment Act of 2021, would assist health departments with recruitment and retention by providing incentives for a workforce whose salaries are not competitive with the private sector. Such a program would align with funding available from ARPA for public health staff hiring while providing an opportunity to build a career in governmental public health.¹⁷⁶ Connecticut, for example, allocated $1 million in ARPA funding to its Department of Public Health for loan repayment. It is important to consider recommendations for improving the NHSC, such as adequate and long-term funding as well as more straightforward participation requirements.¹⁷⁷

Implementing professional development, training, and opportunities for advancement helps support and retain current workers. Moreover, improvements in workplace conditions are needed as the weight of the pandemic takes a toll on workers’ mental health. A 2021 survey found that more than half of the public health workforce experiences symptoms of depression, anxiety, and post-traumatic stress disorder and that these symptoms become more pronounced as hours worked increase and time off decreases.¹⁷⁸ Michigan, for its part, is investing $20 million in workforce support to address these issues—$10 million in trauma-informed management practices and $10 million in employee wellness supports in response to pandemic-related stress and burnout.¹⁷⁹

Despite increasing resignation rates and the challenges brought on by the pandemic, most public health workers have reported being committed to and satisfied with their work.¹⁸⁰ Many public health workers recognize the importance of their work and have a desire to put forth their best effort.¹⁸¹ This shows that public health is a potentially fulfilling career for workers long term—but only if the issues discussed above are addressed. With federal support, public health agencies must reevaluate their cultures and policies to ensure that workers’ needs and well-being are being prioritized. Agency budgets should also prioritize training and professional development for the public health workforce, while also expanding available opportunities for job growth and increased salaries.

Build strategic partnerships and training pathways that can be leveraged during times of crisis to shore up the public health system’s surge capacity

Public health emergencies and threats develop rapidly and require timely responses from a workforce that is trained and prepared in a variety of areas. As demonstrated during the COVID-19 pandemic, a delayed response and lack of capacity can have disastrous consequences on health and safety.

Public health agencies can quickly ramp up their capacity by establishing partnerships with local institutions and professional associations whose membership can help meet workforce needs. For example, Florida state health officials recruited and temporarily hired 100 students and professors from local universities to perform contact tracing.¹⁸² Several other state and local health departments relied on public health schools to increase their capacity.¹⁸³ Private sector partners can be particularly valuable during public health emergencies. Prima County in Arizona, for example, contracted with a private organization in 2020 to hire 150 contact tracers.¹⁸⁴

Building a reserve of retired public health workers who are willing to return during emergencies—especially for high-demand roles such as lab technicians—could also increase surge capacity.¹⁸⁵ During non-emergencies, public health departments should cross-train staff so that their capabilities are flexible and adaptable.¹⁸⁶

Communications

The COVID-19 pandemic has highlighted the costs of a lack of national understanding of governmental public health. Moreover, it has shown the disastrous consequences of a failure to effectively communicate the critical role that public health systems play in creating conditions in which people can be healthy and thrive.

Develop, test, and disseminate clear and consistent messaging on what public health is and why it matters

Confusion and misinformation have dampened trust in science and government, led to harassment of public health officials, and provoked risky actions that can threaten the health of individuals and their communities.¹⁸⁷ As a result, polling shows that most Americans (88 percent) believe that society is more divided now than it was before the pandemic—the highest percentage among the 16 countries polled.¹⁸⁸

Yet public health measures are the road map to a faster and sustained recovery. To address this disconnect, the Public Health Communications Collaborative, formed in 2020, helps coordinate and amplify public health messaging on COVID-19 to increase Americans’ confidence in public health guidance.¹⁸⁹

Generally, public health must rely more on trusted storytellers and spokespeople particularly skilled at communicating complex topics to the public in engaging and accessible ways, rather than just those with scientific backgrounds.¹⁹⁰ Doing so would not only reduce confusion but also build support for public health messages and measures.

Strengthen public-private partnerships to advocate for public health

Persuading lawmakers to increase spending on public health is hampered by a lack of understanding of public health functions and a lack of political clout, even as health care industry groups—such as hospitals, doctors, and pharmaceutical interests—lobby heavily. Unfortunately, organizations that advocate on behalf of health care coverage, access, and cost rarely include public health in their legislative agendas. Yet the health care system should be more oriented to the needs of communities, and in some instances, health care providers do have obligations tied to advance community health.¹⁹¹

COVID-19 has catalyzed action and highlighted the costs of the nation’s crumbling public health infrastructure—for both health and economic well-being. From the increases in infectious disease and biological threats, to the growing impact of climate change on health, to the continued burden of chronic disease, now is the time to fully invest in sustainable public health infrastructure so that these threats to lives and livelihoods can be truly addressed.

Before the next inevitable public health emergency, policymakers must break the pattern of neglect and prioritize modernized public health data capabilities, workforce capacity, preparedness, and effective messaging strategies. The country would be making a critical error if it simply moved on without building on the progress made over the past two years.

The authors would like to thank Nicole Rapfogel of the Center for American Progress for her immense support in finalizing this project and Matt McKillop of Trust for America’s Health for his insight on public health funding. They also acknowledge CAP’s Health Policy, National Security and International Policy, Domestic Climate, Government Affairs, Poverty to Prosperity, and Women’s Initiative teams for their thoughtful review and contribution to this report.

* Correction, May 25, 2022: This report has been updated to clarify when California’s additional annual investment of $300 million for public health will take effect.