1. Budget and priority setting in a time of scarcity JP Leider

2. 2 Presenter Disclosure The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: JP Leider No relationships to disclose ASTHO and JHSPH project team members jointly worked on the conceptualization and execution of this project Thanks to the Johns Hopkins University Preparedness and Emergency Response Research Center for funding part of this project. PERRC did not participate in the conceptualization or execution of this project.

3. Project team (in alphabetical order) Tom Burke, JHSPH JP Leider, JHSPH Beth Resnick, JHSPH Katie Sellers, ASTHO Thanks to: Nancy Kass, JHSPH Joseph Berger, JHU ASTHO staff State Health officials and their staff 3 © 2011, Johns Hopkins University. All rights reserved.

4. Background State Health Agencies (SHAs) are critical players in the public health system The Association of State and Territorial Health Officials (ASTHO) reported that 76% of SHAs made budget cuts during FY09 and 83% have experienced job losses since the beginning of FY2009 Cuts are frequently cumulative The National Association of County and City Health Officials (NACCHO) reported that over 56% of LHDs experienced funding cuts in 2010 4

5. Study overview Stage one of a two-stage mixed methods, exploratory project (Qual->Quan) 45 interviews were conducted in Spring 2011 Transcribed, verified, and double-coded Six state health agencies Approximately seven interviews with executive and division/bureau leadership in each agency 5

6. Results: Top Resource Allocation Criteria Availability of funds Delivery by others Impact on locals and partners Magnitude of problem or size Mandatory match or services Maximize dollars Mission critical Political interests Prevention and protection Seriousness of consequence 6

7. Results: Second-tier Criteria Capacity Cost effectiveness Unsustainable cuts Emerging issues Federal priorities Impact on personnel Means of correcting Previous allocation and results Strength of evidence Target group 7

8. Results: Uncommon Criteria Aligned with strategic plan Community interests Equity promoting Immediate benefit Is service redundant New or expanding program vs maintaining Population based Special interests 8

9. Results: Resource Allocation Criteria 9

10. Results: Hard choices Bureaucracy and politics Causing harm Cutting the core of Public Health Educating policymakers and demonstrating value Equally compelling services, not enough money for both Geographic inequality Impact on individuals 10

11. Results: Hard choices (continued) Respondents at all levels resoundingly communicated that decisions that result in cutting staff are the hardest Both division heads and executives identified ‘equally compelling choices, not enough money’ as choices that were difficult to cut Division heads (as compared to executives) said that hard choices they encounter tend to be tied up in bureaucracy or political influence 11

12. Results: Tradeoffs Administration vs programs Central vs Local Current vs future need Cuts vs human capital Cutting broad vs deep Efficiency vs need Living within means vs unmet need Medicaid vs Public Health One group vs another Political interests vs Public Health interests Public vs Private sector delivery 12

13. Limitations, strengths & next steps Transferability Credibility Dependability Next steps: Stage 2 national survey is in the field Combining with federal austerity scenarios to examine likely pressures and potentially helpful best practices 13

14. Thank you! JP Leider jleider@jhsph.edu 14