Pre-pandemic public health spending didn’t reduce early COVID-19 deaths in major US cities

Spending more on public health did not necessarily save more lives when COVID-19 first swept through America’s largest cities.

That’s the key takeaway from a new study led by Matthew R. Boyce, PhD, a health policy and finance expert with the Texas A&M University School of Public Health, along with two researchers from Georgetown University.

Their study, published in Archives of Public Health, used data from the Lincoln Institute’s Fiscally Standardized Cities database to assess how much the 50 most populous U.S. cities invested in public health between 2015 and 2019—well before the pandemic hit.

Researchers then compared those spending levels with two key outcomes from 2020: official COVID-19 death counts reported by U.S. Centers for Disease Control and Prevention’s National Vital Statistics System and excess deaths—the number of deaths above what would normally be expected in a typical year. To ensure the comparisons across cities were fair and meaningful, they also accounted for differences in population size and structure, income, health insurance coverage and community vulnerability, among other factors.

What they found was surprising: Cities that spent more on public health didn’t necessarily experience fewer COVID-19 deaths during the first year of the pandemic. Instead, the study found that cities with higher levels of education tended to have lower death rates, possibly suggesting that communities’ ability to access, understand and act on health information may be more important than budgets alone.

“We expected well-funded systems to show an advantage, but the signal just wasn’t there,” Boyce said. “What stood out instead were temporal factors, as well as broader social factors, like education.”

Still, the researchers caution against interpreting the results to mean that public health funding doesn’t matter. Instead, the study points to deeper issues with how funding is allocated in the U.S. public health system.

“Budgets often fluctuate from year to year, and much of the money is tied to specific programs or crises,” Boyce said. “This makes it harder for health departments to build the flexible, long-term infrastructure needed to respond effectively to major emergencies like COVID-19.”

According to the researchers, preparing for future pandemics will take more than just increasing public health budgets; it will also require strategy.

“Public health funding alone is not enough,” Boyce said. “If those investments aren’t stable, flexible, and matched with policies that seek to address social issues and reduce inequalities, then we’re still going to be vulnerable when the next emergency hits.”

“What’s needed are sustained, long-term investments in infrastructure, a stronger workforce, smarter funding strategies, and efforts to tackle the root social issues—like gaps in education and income—that shape health outcomes,” Boyce said.