The Public Health Funding Paradox: How Funding the Problem and Solution Impedes Public Health Progress

Spending on Harm

Although the murders of George Floyd, Breonna Taylor, and many others by police are clear examples of government spending on systems that perpetuate harm, the broader systems of criminal justice and immigration enforcement also exemplify spending on harm. When the costs of policing and courts are combined with the costs of operating prisons, jails, parole, and probation, the annual cost of these systems is estimated to be more than $181 billion per year. ¹ Including the expenditures on both the criminal justice and immigration enforcement systems during the 30-year period from 1983 to 2012, the United States spent an estimated $3.4 trillion more on the justice system than it would have had its funding levels been capped at the 1982 level (inflation-adjusted). ² Research finds that imprisonment is an ineffective long-term intervention for violence prevention, ³ and without increases in incarceration, life expectancy from 1981 to 2007 would have extended by almost 2 additional years. ⁴

Policing, sentencing, and incarceration disproportionately target poor people and communities of color and have deleterious effects on health. Police violence and incarceration cause both direct and indirect physical and mental harm. For direct harm, 6295 men were killed by police from 2012 to 2018 ⁵ ; from 2001 to 2014, boys and men aged 15-34 were treated in hospital emergency departments for injuries caused by police at a similar rate to pedestrians injured by motor vehicles. ⁶ People who have been incarcerated are more likely than those who have not to have negative health effects such as death from accidents, substance use, HIV, liver disease, and liver cancer. ⁷ For every year of incarceration, life expectancy decreases by an estimated 2 years, even when controlling for demographic and offense-related factors. ⁸ The current pandemic also reveals the harm caused by incarceration: as of May 18, 2020, seven of the 10 largest COVID-19 outbreak clusters were in jails, prisons, or detention centers. ⁹

The negative effects also ripple across families and communities: young adults with an incarcerated father were more likely to report being diagnosed with high cholesterol, asthma, migraine, depression, posttraumatic stress disorder, and anxiety than young adults without an incarcerated father. ¹⁰

The billions of dollars that fund immigration law enforcement have been shown to cause poor health among immigrants and have spillover effects into broader society. ¹¹ The budget for Enforcement and Removal Operations—the agency that leads detention and deportation of immigrants—had a total budget authority of $7.45 billion in fiscal year 2018 to support enforcement activities. ¹² These enforcement actions include large workplace raids, home raids, and the surveillance and profiling of immigrant and/or racial/ethnic minority communities.

After a raid in 2008 that detained nearly 400 Latino workers in an Iowa town, Latina mothers (regardless of citizenship status) had lower birth-weight infants compared with before the raid; the infants of non-Hispanic White mothers showed no change in birth weight. ¹³ The stress caused by the immigration enforcement system can contribute to increases in systolic blood pressure, increases in body mass index, and decreases in health care use, as well as activate chronic stress processes that lead to poor health for those who experience it.^14-16 For every 2 deportations in the United States, an estimated 1 child who is a US citizen has poorer health as a result of the removal of a primary caregiver or financial provider. ¹⁷

Depriving of Health: Underfunding Marginalized Communities

Federal spending on programs (beyond health care) that are known to improve health for people with low or moderate incomes has been projected to decrease through 2029. ¹⁸ Federal budgets continue to propose shifting massive costs to states. These costs affect strained states and municipalities to the point where they are cutting the very public sector spending known to improve population health. ¹⁹ The COVID-19 pandemic will exacerbate the struggles of states to fund critical public services. Even with federal relief funds and state reserves, states will face an estimated $510 billion budget gap, and without further federal support, most states will make cuts to education and health care—cuts that will delay recovery and undermine public health. ²⁰

An example of population health being devastated by government financial deprivation was the 2014 water crisis in Flint, Michigan. Flint had been struggling financially for years after General Motors left the city; the automotive company employed 80 000 Flint residents in 1978 and 8000 by 2006. Then, from fiscal years 2006 through 2012, Flint lost a cumulative 46% in its 3 largest sources of revenue: property taxes, income taxes, and state shared revenue (which itself declined by 61%, from $20 million to $7.9 million). ²¹ By siphoning shared revenue from municipalities, state officials further compounded Flint’s financial distress, which the state then used to justify the imposition of 5 emergency managers from 2011 to 2015. ²² Emergency managers are unelected officials who impose austerity measures to balance city budgets. These emergency managers imposed cuts onto a community that already had one of the highest unemployment rates in the state (23.3% in 2010) and where 34.9% of residents lived below the federal poverty level in 2009. ²² The decision to change the water source was made by an emergency manager—who was not a Flint resident or accountable to Flint’s predominantly Black residents—claiming it would save the government $5 million. ²³ The decision was approved by the governor’s office. The consequences and costs have been enormous: from the exposure of thousands of children to lead poisoning to the deaths of 12 people from Legionnaires disease. ²⁴ The health damages of the Flint water crisis have already cost taxpayers more than $1 billion. ²⁵

The overburdened network of national, state, and local public health agencies in the United States must attend to traditional public health services (outbreak response, immunizations, disease surveillance, and disease prevention programs) while also addressing the national opioid epidemic, growing rates of chronic diseases, and racial/ethnic health disparities. But as illustrated previously, public health agencies are also responsible for improving the health of communities that have been harmed by immigration enforcement, criminal justice systems, and chronic disinvestment. Although public health increasingly recognizes the outsized role the government plays in funding policies and practices that can harm health, it is increasingly less equipped with the funding, governance structure, and resources it needs to address those harms, given budget cuts at all levels of the public health system. Of the $3.36 trillion spent annually on health care in the United States, only 3% goes to public health. ²⁶ The COVID-19 pandemic has exposed this underfunding and presents an opportunity to overcome this funding paradox.