The state of Georgia plans to spend about $4 billion in state funds on health care programs in Fiscal Year 2021. Most of this spending flows to health care services through Medicaid, the state’s health insurance program serving almost 2 million Georgians. States play an important role in ensuring people can access clinical health care services. Other critical roles include preventing disease and responding to large-scale health-related events such as epidemics and pandemics, including the current COVID-19 pandemic, and natural disasters. These activities are part of the state’s public health work.
About 6 percent of the state’s health-related spending is dedicated to public health. Although it is the smallest portion of health spending, public health investments can deliver strong returns. For example, supportive housing programs for high-need patients save between $2 to $6 for every $1 invested, and lead abatement programs save between $17 to $221 for every $1 invested. In order to improve the health of Georgians and contain state health care costs in the long run, the state must increase its focus on preventing people from getting sick. Total state and federal funding for public health has remained relatively flat in Georgia, and with the proposed budget cuts for fiscal year 2021, public health spending would revert to fiscal year 2017 levels—at a time when public health is needed the most.
The COVID-19 pandemic brought increased attention to the public health system, which is often considered to be “invisible” when there are not health emergencies. This policy brief will provide background on how the state’s public health system is organized and examine trends in public health spending in Georgia. It will also highlight some of the state’s key public health priorities and why continued investment in them will help in the COVID-19 response and preparation for future emergency events.
Georgia’s Public Health System
Prior to 2011, the state public health system was spread throughout larger agencies including the Department of Human Resources and the Department of Community Health. In 2009, the state created the Public Health Commission, an independent panel of nine experts. From 2000 to 2010, the state’s population grew by 20 percent, and health care expenditures grew by 100 percent. However, public health spending dropped by 20 percent.[1] As a result of the declining budget and the bureaucratic barriers of residing within a larger agency, the commission recommended the state create a standalone agency for public health.[2] The General Assembly created the Department of Public Health in 2011 through legislative language in HB 214 and in the budget passed during the 2011 legislative session. The Georgia Department of Public Health employs about 6,000 people and is led by a Commissioner, who serves at the state’s health officer.[3] The agency has 9 divisions that are divided into 40 programs and offices.[4] The nine-member State Board of Public Health provides oversight of the agency.
Georgia’s Local Health Departments: The Frontline for Health Programs and Services in Rural Communities
In the FY 2020 budget, about 46 percent of the state general funds for the Department of Public Health were distributed as grants to local health departments. Georgia has 159 local health departments—one in each county—that employ a total of 4,453 people.[5] They provide a frontline resource for meeting the public health needs of communities. The local health departments are led by the county board of health and staff employed by the local government. Each local health department is part of one of the state’s 18 public health districts. The regional district offices are led by a health director who is employed by the state government. The district offices provide technical assistance and administrative support such as billing and data analysis for the county health departments. The county health departments deliver direct services including women and children’s health services, immunizations, treatment for sexually transmitted diseases, education programs, restaurant inspections, youth development programs, HIV screening and emergency response activities.[6]
Local health departments receive money from the state and county, service fees and grants. County health departments receive both general and programmatic “grant-in-aid” funding from the state through the district health offices. General grant-in-aid is the funding appropriated by the governor and the General Assembly, and it can be used broadly for health programs. The formula for determining general grant allocations considers the county population and financial resources, meaning rural counties typically receive more funding per person than larger counties.[7] Programmatic grant-in-aid is federal money that is required to be spent on specific programs and goals.[8] Counties are required to provide “participating funds” as a prerequisite for receiving general grant-in-aid money from the state. Counties may also provide more money beyond the participating funds for meeting specific needs. These are called “non-participating funds,” and they are free from the constraints placed on other funds. In addition to county and state funding, local health departments can apply for private or government grants. These grants are usually for specific projects and not for general programs. Lastly, health departments collect revenue such as health inspection fees paid by businesses and sliding-scale fees for health services that are based on income. County health departments are not allowed to deny services based on a patient’s inability to pay.[9]
Every local health department has telehealth capabilities as of December 2012. This allows for patients to receive consultation and referrals to specialists and allows providers to remotely monitor patients.[10]
Public Health Funding Changes
About 60 percent of the funding for the Georgia Department of Public Health comes from the federal government. Most of the federal public health money going to states is distributed through the Centers for Disease Control and Prevention (CDC). The CDC’s budget has remained flat for the last decade, adjusting for inflation. Some spending, such as grants to support emergency preparedness in states, has been cut over the past 15 years. Georgia’s largest source of federal public health funding is for the Women, Infants, and Children (WIC) Supplemental Nutrition Program. This program provides education and money to buy authorized healthy foods for pregnant and postpartum women, breastfeeding mothers and children between ages 1 to 5 in families with low household incomes.[11]
Georgia received $474 million in federal public health funds in fiscal year (FY) 2009, but this amount dropped to $396 million in fiscal year 2020. As a result, the state has needed to increase its investment to maintain the public health department’s overall budget. In FY 2009, the state allocated $191 million in general funds for public health, and this increased to $277 million for fiscal year 2020. The state’s public health investments increased from $19.95 per person in 2009 to $26.98 in 2020. While the state made important strides to increase its public health investment, the overall budget for the department has seen only a modest increase compared to population growth in the past 11 years ($665 million in fiscal year 2009 to $698 million in fiscal year 2020). The total state and federal public health budget amounted to $69.22 per person in 2009 and dropped to $64.46 per person in 2020. Proposed budget cuts in 2021 could bring spending down to $60.05 per person. Georgia’s population increased by 11 percent from 2009 to 2020. To maintain the per-person spending levels the state had in FY 2009, the overall public health budget should be at $749 million in fiscal year 2020, instead of $698 million.
Within the Department of Public Health, there are dozens of categories of spending, and the budget trends vary for each category. Categories that are especially critical in the response to COVID-19 and preparation for outbreaks and disasters include emergency preparedness and trauma system improvements and epidemiology.
Epidemiology
The Epidemiology division of the agency is responsible for monitoring, investigating and responding to diseases and other public health concerns. The division was cut significantly due to budget shortfalls during the Great Recession, which strained the state’s capacity to track conditions. Although state investment has grown, it still has not reached pre-recession levels, making it difficult for the state to have the capacity it needs to monitor and respond to COVID-19. A larger investment in this division would help with ensuring real-time data quality and transparency for COVID-19 and other health conditions.
Emergency Preparedness and Trauma System Improvement
The state allocated about $3.8 million in state general funds and $23.8 million in federal funds towards preparing for natural disasters, bioterrorism and other emergencies, along with improving the state’s trauma system capacity. The amount of spending in this area dropped significantly in 2015 as a result of cuts to federal emergency preparedness grants. Georgia ranks in the middle tier of states in terms of the level of preparedness for an emergency, indicating a need to prioritize a stronger system of preparation for future emergencies.[12]
Ongoing Public Health Needs
While COVID-19 will be the agency’s top priority for an indefinite period, there are a number of other needs that the agency made strides to address before the pandemic that will need continued attention and resources. Some of the agency’s top priorities in the last decade include improving the state’s outcomes for HIV/AIDS, maternal and infant health and chronic disease. In all of these priority areas—and the current COVID-19 pandemic—racism has a significant influence on outcomes.
Black Georgians experience worse outcomes in all of these areas than other racial and ethnic groups. Systemic racism contributes to health inequity in many ways; for example, Black people face unfavorable bias when seeking health services, experience higher levels of toxic stress due to persistent racism and are more likely to live in a community with fewer resources to stay healthy, due to a history of segregation and housing discrimination. For Georgia to address priority issues like COVID-19, HIV/AIDS, maternal and infant health and chronic disease, racism needs to be treated as a public health crisis, and public health resources need to be directed to Black communities. The following sections outline some ways public health can respond to these key needs.
HIV and AIDS
Georgia had the second-highest rate of HIV diagnoses across all states in 2018.[13] Black people were 72 percent of the new HIV diagnoses in Georgia in 2017.[14] The Georgia Department of Public Health has an Office of HIV/AIDS that connects people living with HIV with health care and support services and manages the federal funding the state receives for HIV care through the Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS program. Services provided through this program include the Healthcare Insurance Continuation Program (HICP) that assists people with HIV/AIDS in paying for insurance premiums and the AIDS Drug Assistance Program (ADAP) that provides HIV/AIDS medications to people without health insurance. In September of 2011, the program had a waiting list of 1,778 people.[15] In 2012, due to new provisions from the federal Affordable Care Act, the public health department eliminated the waiting list for ADAP using savings accrued by moving patients to insurance plans for people with pre-existing conditions.
Local public health departments respond to the HIV epidemic through testing, education and treatment initiatives. The federal government outlined Cobb, DeKalb, Fulton and Gwinnett counties as the priority areas in Georgia in its plan to end the HIV epidemic by 2030. Thus far, the counties have been awarded almost $2 million for their Ryan White programs, and more federal funding is expected to help these counties prevent and treat HIV and AIDS.[16] This federal funding should focus on creating new initiatives and increasing capacity; the state should not see them as an opportunity to decrease state funding that is currently allocated for services in these counties. State spending on infectious disease control—which includes the Office of HIV/AIDS—is already flat, so increased capacity is needed to successfully respond to the HIV epidemic in Georgia.
The state can support innovative programs like the three-year pilot program to provide pre-exposure prophylaxis (commonly called PrEP) to people with a high risk of contracting HIV. Legislation passed last year to allow the Department of Public Health to start the program, but the Legislature needs to appropriate about $57,000 in the FY 2021 budget to administer the first year of the program.
Maternal and Infant Health
One of the Department of Public Health’s top priorities is improving infant health by preventing low birthweight or preterm birth. Georgia has the seventh highest infant mortality rate among states, and the rate is two times higher for Black infants than white infants.[17] One successful initiative in reducing preterm births is the pregnancy centering program, which provides group prenatal care for women between 16 and 40 weeks of pregnancy. Participants in the Dougherty County centering program had a preterm birth rate of 5.9 percent compared to baseline measurement of 13.8 percent for white county residents and 17.6 percent for Black county residents.[18]
The state’s public health efforts are helping to improve infant health, but the bigger challenge now is maternal health. Georgia ranks no. 49 among states for the rate of maternal mortality, defined as deaths related to pregnancy that occur during or within one year of pregnancy or birth. The maternal mortality rates for Black women in Georgia are three to four times higher than for white women. Georgia lawmakers have increased their attention on maternal health, most recently with a $2 million appropriation in the Department of Public Health’s fiscal year 2019 budget to address maternal mortality. However, $1.5 million of this funding is at risk of being cut in the proposed fiscal year 2021 budget. The state can support public health efforts to prevent maternal deaths by restoring this funding in the 2021 budget and supporting an extension of Medicaid benefits for a year after birth.
Chronic Disease
The state’s chronic disease epidemiologists track conditions like asthma, cancer, cardiovascular disease, diabetes and obesity, and the agency’s chronic disease prevention unit manages programs related to these conditions. The state has increased its investment in adolescent and adult health promotion, which includes activities like cancer screening and tobacco use prevention. But the proposed FY 2021 budget would bring total spending for adolescent and adult health promotion back to its FY 2016 level. In addition to chronic disease prevention, the agency also has some programs to help pay for chronic disease treatment. The state’s spending on treatment services for low-income people with cancer or at risk of heart disease zeroed out in fiscal year 2015—from $12.4 million in fiscal year 2009—and is now completely federally funded.
An estimated 34,500 lives could be saved each year through better prevention and treatment of chronic disease in Georgia.[19] Although most adults—60 percent—have a chronic disease, the impact of slavery on health and the ongoing effects of racism and discrimination have led to higher rates of most chronic diseases in Black communities. For example, the number of heart disease deaths in Georgia per 100,000 is 190.3 for Black residents compared to 173.6 for white residents.[20] And Black Georgia adults are more likely to report having asthma and diabetes than adults as a whole.[21] The FY 2021 budget proposed cutting grants to organizations focused on chronic diseases, such as cancer and sickle cell disease. With fewer resources to help manage and prevent chronic illnesses, cuts to public health efforts on chronic disease will leave the state continuing to face higher health care costs and will continue to expose Black communities to greater risk from COVID-19 and other emerging health challenges.
Looking Ahead
State and federal lawmakers can take action to support public health in Georgia. In the short term, state lawmakers can protect public health by rejecting funding cuts to local health departments. The state public health agency is expecting to cut $18 million from grants to local health departments. The local health departments are necessary for frontline care for many Georgians and need to maintain their capacity to continue COVID-19 testing and contact tracing efforts, as well as delivering the vaccine as it becomes available. Rural counties receive larger state public health grants per capita because they often do not have as many local revenue sources to fund their health departments as larger and wealthier counties do. Cuts to these grants could make it more difficult for rural health departments to maintain services, since they have fewer local resources to fill the gap.
At the state level, it is important that Georgia maintains its increased investment in public health and makes targeted high-value investments for key public health priorities. The Department of Public Health is set to be cut by $37 million for the 2021 budget, unless lawmakers prevent these deep proposed cuts. With continued population growth and pressing health needs to address, cuts to public health funding would be a setback in the state’s progress. The state should examine options to better leverage Medicaid to increase payments for services provided at local health departments, which will reduce the amount of state general funds needed to sustain each health department.[22] The state can also be strategic with its investments by prioritizing more evidence-based strategies with proven savings and health benefits. For example, the CDC compiled top strategies through its Health Impact in 5 Years Initiative. One of these strategies is the Earned Income Tax Credit, which improves health by helping working families keep more of their wages. Georgia can join 29 other states in enacting a state earned income tax credit known as the Georgia Work Credit.[23]
At the federal level, Congress can enhance funding for the Centers for Disease Control and Prevention (CDC) and fully fund the Prevention and Public Health Fund that was enacted in 2010 under the Affordable Care Act. The U.S. Congress is set to allocate $11.85 billion fewer dollars to the fund than what was enacted under the law. The state received about $40 million in funding from the CDC for COVID-19 response, but additional funding may be needed to allow them to continue the response and maintain other programs.
Endnotes
[1] Georgia Watch. (2010, December 14). State commission: Georgia needs independent public health agency. https://georgiawatch.org/state-commission-georgia-needs-independent-public-health-agency/
[2] Georgia Public Health Commission. (2010, December 1). Report to the governor, the speaker, and the lieutenant governor: O.C.G.A. 31-2-10. Georgia Public Health Association. https://www.gapha.org/wp-content/uploads/2010/12/CommissionReport.pdf
[3] Georgia Department of Public Health. (2020). Commissioner’s message. https://dph.georgia.gov/about-dph/commissioners-message
[4] Georgia Department of Public Health. (2018, July). FY 19 strategic plan update. https://dph.georgia.gov/about-dph/mission-and-values
[5] List of County Board of Health Employees as of September 30, 2019, obtained from the Georgia Department of Public Health.
[6] Kroening, S. (2018, November 7). DPH priorities and statewide initiatives [PowerPoint slides]. Children’s Healthcare of Atlanta. https://www.choa.org/~/media/files/Childrens/medical-professionals/nursing-resources/school-health-fall-leadership-conference-2018/dph-update-sara-kroening.pdf?la=en
[7] Georgia House of Representatives Research Office. (2006). House of Representatives Study Committee on Public Health: Final report. Georgia Public Health Association. https://www.gapha.org/wp-content/uploads/2008/05/ph-study-committee-f_24d708.pdf
[8] Rollins School of Public Health, Emory University. (2015). Financing public health in Georgia (Board of Health Video Training Project). Region IV Public Health Training Center. http://www.r4phtc.org/wp-content/uploads/2016/03/BOH_Financing-PH-in-Georgia.pdf
[9] Rollins School of Public Health, Emory University. (2015). Financing public health in Georgia (Board of Health Video Training Project). Region IV Public Health Training Center. http://www.r4phtc.org/wp-content/uploads/2016/03/BOH_Financing-PH-in-Georgia.pdf
[10] Georgia Department of Public Health. (2013, January 24). AFY2013 and FY2014 budget presentation to Joint Appropriations Committee [PowerPoint slides]. https://dph.georgia.gov/sites/dph.georgia.gov/files/related_files/site_page/AFY13_FY14%20DPH%20Joint%20Appropriation%20Meeting_012413.pdf
[11] Georgia Department of Public Health. (2020). Georgia WIC. https://dph.georgia.gov/WIC
[12] Trust for America’s Health. (2020, February). Ready or not 2020: Protecting the public’s health from diseases, disasters and bioterrorism. https://www.tfah.org/report-details/readyornot2020/
[13] Kaiser Family Foundation, State Health Facts. (2020). HIV diagnoses, adults and adolescents.
[14] AIDSVu. Local Data: Georgia. https://aidsvu.org/local-data/united-states/south/georgia/
[15] Georgia Department of Public Health. (2013, January 24). AFY2013 and FY2014 budget presentation to Joint Appropriations Committee [PowerPoint slides]. https://dph.georgia.gov/sites/dph.georgia.gov/files/related_files/site_page/AFY13_FY14%20DPH%20Joint%20Appropriation%20Meeting_012413.pdf
[16] Health Resources and Services Administration. (2020, February). FY 2020 Ending the HIV Epidemic Awards. https://hab.hrsa.gov/about-ryan-white-hivaids-program/fy2020-ending-hiv-epidemic-awards
[17] Georgia Department of Public Health (2017). Infant Mortality Report. http://www.dph.georgia.gov/infant-mortality
[18] Georgia Department of Public Health. (2013, January 24). AFY2013 and FY2014 budget presentation to Joint Appropriations Committee [PowerPoint slides]. https://dph.georgia.gov/sites/dph.georgia.gov/files/related_files/site_page/AFY13_FY14%20DPH%20Joint%20Appropriation%20Meeting_012413.pdf
[19] Partnership to Fight Chronic Disease. (2020). What is the impact of chronic disease on Georgia? https://www.fightchronicdisease.org/georgia
[20] Kaiser Family Foundation, State Health Facts. (2020). Number of heart disease deaths per 100,000 population by race/ethnicity.
[21] Kaiser Family Foundation, State Health Facts. (2020). Adults who report ever being told by a doctor that they have diabetes by race/ethnicity.
Kaiser Family Foundation, State Health Facts. (2020). Adults who report currently having asthma by race/ethnicity.
[22] Harker, L. (2019, September 9). Opportunities for Georgia to best leverage Medicaid waivers. Georgia Budget and Policy Institute. https://gbpi.org/opportunities-for-georgia-to-best-leverage-medicaid-waivers/
[23] Camardelle, A. (2019, June 25). The earned income tax credit and young adult workers. Georgia Budget and Policy Institute. https://gbpi.org/the-earned-income-tax-credit-and-young-adult-workers/
