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WASHINGTON — As coronavirus infections spread across the country, the outbreak will test America’s unusually decentralized public health system, spotlighting large gaps in some states’ readiness to confront a major health crisis.
That threatens to exacerbate an outbreak that has already infected more than 1,000 Americans, but is expected to grow dramatically in coming weeks and put severe strains on medical providers around the country.
Nationwide, spending on public health varies dramatically between those states and local governments that have invested and others that have allowed public health departments to wither in recent years.
In Florida, for example, where a large population of seniors makes the state particularly vulnerable to the coronavirus, state funding for county health departments is below what it was a decade ago.
The cuts have forced some counties to shutter clinics, threatening to worsen the state’s problems with access to health care, said Anne Swerlick, senior health policy analyst at the nonprofit Florida Policy Institute. “There used to be a lot more capacity to provide more primary care services,” she said.
California, too, has seen a steady erosion in public health investment, forcing counties to cut epidemiologists, public health nurses, lab technicians and others, said Michelle Gibbons, executive director of the County Health Executives Assn. of California.
“One of the challenges is that there is a lot of investigation that’s needed right now, and that puts a huge strain on existing staffing,” she said.
Nationwide, state and local public health departments lost more than 50,000 workers following the 2008 recession, said John Auerbach, head of the nonprofit Trust for America’s Health, which tracks state-by-state public health preparedness.
Many jobs have yet to be restored. Over the same time period, public health emergency preparedness funds were cut by a third and hospital preparedness funds by half.
“If a state has not invested heavily in its public health department, it’s going to have fewer people available to do the laboratory work, the epidemiologic work, the communication work with the public, and the coordination with hospitals and healthcare providers,” Auerbach said.
In addition to the variations in the public health systems, there are huge disparities between states in insurance coverage, as many conservativeleaning states restrict access to the Medicaid safety net. That leaves several million low-income Americans without health insurance, a major hurdle during an infectious-disease outbreak.
Differences in the availability of paid sick time also mean many more workers in some states face pressure to stay on the job, even if they are ill, making it harder to contain the spread of disease.
“When you look across the country, there is just an enormous amount of variation,” said Dr. Georges Benjamin, the longtime executive director of the American Public Health Assn.
“States that haven’t invested worry me the most, and their health statistics show the results,” Benjamin added. “But there seems to be a fundamental lack of understanding about why those investments are important.”
Most wealthy nations maintain more centralized health systems, ensuring more uniform standards of protection, according to experts.
But in the U.S., public health has long been a state or local responsibility, with funding supplemented by the federal government, often only episodically.
That can make mobilizing local efforts more difficult, said Jeffrey Levi, a professor at Milken Institute School of Public Health at George Washington University.
“What we have added into the mix now is confused messaging from the federal government,” Levi said, noting the Trump administration’s often contradictory statements about the seriousness of the coronavirus threat.
Comparing public health spending among states is difficult because states often account for money very differently, but cutbacks have been clear in many places.
Mississippi, for example, slashed the state health department budget by nearly a third in 2017, forcing the agency to cut clinics and curtail efforts to control tuberculosis.