Transcript Who Gets How Much? Assessing Strategies for Formula

Who Gets How Much?
Assessing Strategies for
Formula-Based Allocation of Public Health Funds
Public Health Systems Research
April 21, 2006
James Buehler, MD
Department of Epidemiology and Center for Public Health Preparedness & Research
Rollins School of Public Health, Emory University
and
Epidemiology Branch, Division of Public Health, Georgia Department of Human Resources
David Holtgrave, PhD
Department of Health, Behavior, and Society, Bloomberg School of Public Health,
Johns Hopkins University
CDC Cooperative Agreement on Public Health
Preparedness and Response for Bioterrorism.
Budget Year Five, Issued June 2004
http://www.bt.cdc.gov/planning/continuationguidance/index.asp
“Each state awardee will receive a base
amount of $3,915,000, plus an amount
equal to its proportional share of the
national population as reflected in the
U.S. Census estimates for July 1, 2002.”
This apportionment does not take into account
differences among states in…
• Likelihood of terrorist attack
• Vulnerability of critical
infrastructure
• Transport hubs
• Cost of doing business
• Geography: size,
international borders,
coastline
• Vulnerable populations
• Local resources
• Likelihood of natural disaster
• Existing capacity
• Etc. …
Let’s make a new formula that takes these
factors into account
• Likelihood of terrorist attack All we need is:
• A relevant data source for each of
• Vulnerability of critical
infrastructure
these measures
• Transport hubs
• Agreement on how each should
• Cost of doing business
be weighted
• Geography: size, international
borders, coastline
• Vulnerable populations
• Local resources
–Simple & transparent
• Likelihood of natural disaster
–Quick & easy
• Existing capacity
• Etc. …
–Sensible that states with
Maybe CDC formula is OK
more people need more
resources
Overview
– Lessons from prior reviews
– Formulas used by selected federal public
health programs
– Recommendations for research
Image source:
www.1az.cz
National Academy of Sciences
Panel on Formula Allocations
Convened in 2000
• In FY-1999-2000, the federal government allocated >$250 billion
per year using formulas
– Medicaid, highway construction, education, WIC, social services
• Formula elements:
–
–
–
–
Data source(s)
Threshold for eligibility
Guaranteed minimum funding
The formula:
• Simple to complex
• Some account for differences in costs or local resources
– "Hold-harmless" provisions
– Funding ceilings
Panel on Formula Allocations. Choosing the Right Formula: Initial Report. National Academies Press, 2001.
Panel on Formula Allocations. Statistical Issues in Allocating Funds by Formula. National Academies Press, 2003.
NAS Panel on Formula Allocations
Possible adverse or unintended
consequences of formula-based funding
• Substantial variations in "per capita" funding
may undermine perceived fairness, due to:
–
–
–
–
"Hold-harmless" agreements
Guaranteed minimum funding
Random variability of source data
Mismatch between data source and program target
population or goals
– Differences among funded areas not taken into
account by formulas
• Unintended effects on data sources
The Ryan White HIV CARE Program
(HRSA)
• Safety net care program for people with HIV
• The data source imperfect: AIDS
– AIDS = the late stage of HIV disease
– Congressional mandate to include HIV data
– Includes many ineligible for “safety net” program
• Early effort to account for cost differences abandoned.
• Cumulative AIDS reports, changed to people living with AIDS.
– “Hold-harmless" provision  variations in "per case" funding
• Data collected by grantees
– Variable surveillance capacity
– Especially for HIV reporting
• Showdown looming over name-based versus unique identifier
reporting
Committee on the Ryan White CARE Act: Data for Resource Allocation, Planning and
Evaluation. Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan
White CARE Act. National Academies Press, Washington DC, 2004.
Formula Funding
Can Affect
Source Data
AIDS Reporting and Ryan
White HIV CARE program
1993 Revision of
AIDS Definition 
Shift from Cumulative AIDS Reports to People Living with AIDS:
• Potential disincentive to assure deaths ascertained and
AIDS reports updated
• Averted by applying national estimate of AIDS death rates to
all state AIDS reports
Graph source: CDC
Trends in Disease A, Two States,
2000-2005
2000
Number of
Cases
Decisions should
be based on data
1500
1000
500
0
1998
2000
2002
2004
2006
Year of Report
State A
State B
• Number of cases in 2005  Each state gets 50% of funds.
• Average annual number of cases for 2000-2005 38% for State A
and 62% for State B.
• Would formula differ for program aimed at:
– Prevention of Disease A?
– Treatment of Disease A?
CDC Public Health Emergency Preparedness, July 2005
(http://www.bt.cdc.gov/planning/guidance05/)
• Objective: "to upgrade… preparedness for…terrorism and
other public health emergencies”
• Funds Available: $862 million, FY-2005
• $809,956,000:
"Each State…will receive a base amount of $3.91 million,
plus an amount equal to its proportional share of the
national population as reflected in the U.S. Census estimates
for July 1, 2003."
• $40,181,000: City Readiness Initiative, 30 urban areas
• $ 5,440,000: Early Warning Infectious Disease
Surveillance, Border states
• $ 7,200,000: Chemical laboratory funding, 5 states
CDC Pandemic Influenza State & Local
Government Planning & Response Activities
http://www.pandemicflu.gov
• Objective: "to accelerate and
intensify…planning … for pandemic influenza."
• Funds Available: $350 million:
• $ 100 million, January 2006 (Phase I):
– Formula Description: "Each state will receive a
minimum of $500,000, and the rest of the funds will
be allocated by population."
• “The remaining $250 million…will be awarded
later…in accord with…progress and
performance.”
Formulas Are Not as Transparent
as They Appear
Example: Pandemic Influenza funding
The allocation cannot be recreated using
published information:
– Which year's Census data were used?
– How were funding levels determined for
Puerto Rico, separately funded local areas,
and Territories?
– Order of calculations?
HRSA Maternal and Child Health Services Block Grant
ftp://ftp.hrsa.gov/mchb/titlevtoday/UnderstandingTitleV.pdf
•
•
•
Objectives: “…improving the health of all mothers and
children,” “gap filling” clinical services, “population-based
functions,” and programs for “children with special
healthcare needs.”
Funds Available: >80% of funds are awarded to
states ($594 million in FY-2004). Formula based on:
1. “the amount awarded to the states in 1981 for the
pre-block programs later consolidated into the State
grant” (~3/4 of funds)
2. “the remaining amount is distributed based on the
proportion of low income children that a State bears
to the total number of such children for all the States.”
Remaining funds ($135 million in FY-2004) “are
awarded on a competitive basis to a variety of applicant
organizations” for special projects.
CDC Preventive Health and Health Services Block Grant
http://www.cdc.gov/programs/chron06.htm
http://www.federalgrantswire.com/preventive_health_and_health_services_block_grant.html
• Objectives: “a…flexible public health resource”
• Funds Available: $129 million FY-2004.
– $121 Million: “an allocation percentage is determined for
each State based on the amounts of fiscal year 1981 funds
provided to the State for certain categorical health grants
that were combined to comprise the...block grant to the total
amount of fiscal year 1981 funds appropriated for these
grant programs.”
– $8 million: “For…Rape Prevention portion of the block
grant…allocated to States based on the percentage of each
State's population to the national population.”
Per Capita Funding by Area Population, 3 CDC Grant Programs
CDC PH Emergency Preparedness Funding
Program, FY2005, States and Separately Funded
Cities/Counties, Per Capita Allocation
CDC Preventive Health and Health Services Block
Grant, FY2004, States and Separately Funded
Cities/Counties, Per Capita Allocation
$2.00
$25.00
$1.80
Per Capita Allocation
$15.00
$10.00
$5.00
$1.40
$1.20
$1.00
$0.80
$0.60
$0.40
$0.20
$0
5,000,000
10,000,000
15,000,000
20,000,000
25,000,000
$-
30,000,000
0
5,000,000
Area Population
10,000,000
15,000,000
20,000,000
Area Population
CDC Pandemic Influenza Planning Funds, 2006
States and Separately Funded Cities/Counties,
Per Capita Allocation
$1.40
$1.20
Per Capita Allocation
Per Capita Allocation
$1.60
$20.00
$1.00
$0.80
$0.60
$0.40
$0.20
$0
5,000,000
10,000,000
15,000,000
20,000,000
Area Population
25,000,000
30,000,000
25,000,000
30,000,000
Conclusions (1)
• Formulas aim for effective allocation
of resources to realize program
objectives
– Transparency
– Feasibility
– Efficacy and Effectiveness
– “Fairness”: Equivalency? Equity?
Conclusions (2)
• Federal public health programs formulas
generally:
– Provide a minimum funding level to all grantees
– Rationale not provided for
• Guaranteed minimums
• Designations for selected cities, PR, territories
– Do not account for program costs
– Set asides for designated or competitive awards
• Baseline minimum funding shapes "per
capita" allocation
Recommendations for Research
– Build on findings from the NAS Panel on
Formula Allocations and reviews of the Ryan
White HIV CARE program
– Assess the feasibility of accounting for local
costs and resources.
– Refine strategies for determining baseline
minimums
– Focus on the unique questions surrounding
allocations for prevention programs
– Consider how formulas
• Reflect values
• Are subject to manipulation
Images: CDC Protecting Health for Live, The State of CDC FY 2004
http://www.cdc.gov/od/oc/media/pressrel/socdc04.pdf