The Impacts of Local Health Department Consolidation on Public Health Expenditures: Evidence From Ohio

摘要

We examined the effects of local health department (LHD) consolidations on the total and administrative expenditures of LHDs in Ohio from 2001 to 2011. We obtained data from annual records maintained by the state of Ohio and through interviews conducted with senior local health officials and identified 20 consolidations of LHDs occurring in Ohio in this time period. We found that consolidating LHDs experienced a reduction in total expenditures of approximately 16% ( P =?.017), although we found no statistically significant change in administrative expenses. County health officials who were interviewed concurred that their consolidations yielded financial benefits, and they also asserted that their consolidations yielded public health service improvements. Local health departments (LHDs) play a central role in providing public health services. However, since the turn of the 21st century, pressure has mounted on state and local government budgets, forcing LHDs to make hard decisions regarding resource allocation. The LHD workforce (in full-time equivalents) decreased by an estimated 12% from 2008 to 2013, with nearly one half (48%) of all LHDs reducing or eliminating services in at least 1 program area in 2012. 1,2 The options that many LHDs around the country are considering to ameliorate fiscal pressures include cross-jurisdictional sharing and organizational redesign, including LHD consolidation. Recent studies have supported the idea that consolidating LHDs may increase efficiency and improve the effectiveness of public health services. Santerre 3 suggested that economies of scale achieved through health department consolidation may improve cost-effectiveness of service provision. Mays et al. analyzed public health performance information from multiple states and concluded that consolidation “may hold promise for improving the performance of essential services.” 4 (p523) More recently, Hoornbeek et al. 5 reported evidence of cost savings, as well as other perceived benefits, associated with the consolidation of LHDs in northeastern Ohio. Ohio has witnessed at least 20 consolidations of LHDs serving more than 2.6 million Ohioans since 2001. Most consolidations came about from voluntary agreements between cities and counties. The number of consolidations in Ohio, and statewide reporting systems documenting LHD finances, provide an opportunity to improve our understanding of the impacts of LHD consolidation. Do consolidations lead to positive financial impacts, including lower expenditures, as one might expect? Using a mixed-methods approach, we address this question by presenting a quantitative analysis of data on Ohio LHDs and findings from interviews with local health officials (LHOs) from these consolidated LHDs. Our study contributes to the literature on LHD consolidation in at least 3 ways. First, previous studies have suggested that LHD consolidations may result in cost efficiencies, 3 but none of those studies reviewed evidence from multiple LHD consolidations over an extended period of time. Second, because consolidations in Ohio took place over a number of years, we were able to model the independent effects of time on the outcome variables, thus controlling for the impact of external trends on LHD expenditures. Third, we focused our study on multiple LHDs in a single state. Because states differ in their economic, political, and legislative landscapes, cross-state comparisons of LHDs may not always be appropriate. By focusing on a single state, we captured potentially idiosyncratic features that influence LHD consolidation in Ohio and their impact on our expenditure-related outcome variables. Thus, unlike past studies, this research enables scholars and practitioners to look at the temporal evolution of multiple LHD consolidations in a single-state setting.