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Public health spending in the Cape Fear region has declined for over a decade

New Hanover County Health and Human Services building
Benjamin Schachtman
The New Hanover County Health and Human Services building.

In the Cape Fear region, spending for public health has been dropping for close to a decade. Some of the reasons that account for this are the decrease in program offerings and the rise of private and non-profit health services, but some officials would like to see funding boosted.

Expenditures have gone down. Why?

Public health departments provide services like inspections of schools and restaurants, communicable disease prevention, and maternal health.

But over the past decade, county health departments across the state have decreased their spending. It’s a trend consistent with about half of the counties in North Carolina.

According to the Raleigh News and Observer, the state does not keep annual expenditures in one place, so WHQR has compiled this yearly spending for New Hanover, Brunswick, and Pender counties to analyze.

From this analysis, public health spending in the Cape Fear region from 2011 to 2020 has dropped by more than 19% when adjusted for inflation and population increase.

More specifically, in New Hanover County, over the past nine years spending has dropped about 30%. In Brunswick, a 23% decline, and in Pender, it’s about a 5% percent decrease.

Rachel Keith
According to UNC's Ryan Thornburg, "Across the state, county-level spending on public health dropped 22% from 2010-2018 when adjusted for inflation and the change in population."

Carolyn Moser has been the Director of Pender County’s Health and Human Services Department for about ten years. She said one reason for the decline in spending, programming mandates change from year to year: “We had an animal shelter, briefly when I came, and it was transferred to the sheriff’s department, which now it’s back over to me. We didn’t have mosquito control; now it’s back with me. We were the medical director for school-based health centers and this coming year, we will no longer do that."

Cris Harrelson, the public health director for Brunswick County, said they too moved animal control over to the sheriff’s office. In addition, they lost some emergency funding and closed their adult health clinic.

“So over the course of these ten years, just with the reduction in those programs, we’ve reduced our expenditures by $1.7 million," Harrelson said.

The growth of both the private and non-profit health sectors has also contributed to Harrelson's department offering fewer services: “That’s one of the biggest reasons we closed our adult health clinic back in the fiscal year 2014-2015, is that there were federally qualified health centers and other nonprofits that were meeting the needs of the indigent population and low-income population. Our government at the time felt that was not a role for the government to be when it was readily available in the community."

BC Bldg.jpg
Brunswick County
Harrelson says that his department needs to focus on their "community health assessment priorities in the future, which is substance abuse and addiction; chronic disease and access to care."

David Howard, the public health director for New Hanover County, agreed with Moser and Harrelson that jobs and programs have changed over time — and that they sometimes end up in other county departments.

“Overall I think we have multiplied some of the public health work we do through mechanisms that don’t necessarily reflect in dollars and cents on the budget that we report out as being strictly the budget for public health. 90% or over what we have in terms of expenditures is personnel," Howard said.

New Hanover County Flickr page
New Hanover County Manager Chris Coudriet at the dedication of the new Department of Health and Human Services Building in October 2019.

The largest drop in spending, close to a 15% decrease in 2014, according to Howard, was because they consolidated their positions with the overall Department of Social Services and Public Health: “We executed something that we called functional collaboration, where we combined a good bit of our administrative staff and our finance team to work more closely with our county finance."

Are there years when public health spending has increased?

Spending hasn’t decreased uniformly: public health departments in the Cape Fear region have increased expenditures in certain years when there’s an emergency or an additional program offering for that year.

Take, for example, Pender County’s expenditures in 2014, which was close to $110 per person. Moser said that was due to grant funding for a migrant health program, pay increases for staff, and the hiring of additional dentists.

Harrelson said Brunswick County saw a significant increase in funding in 2011, about $381,000, to fight the H1N1 swine flu. For New Hanover County, Howard said the largest yearly increase in 2013, of about 5%, was attributed to an infusion of capital money for upgrades to their health clinic.

Moser, Harrelson, and Howard all said they’ll likely see their spending increase by $1 to $2 million for the fiscal year 2021 because of additional state and federal funding to combat Covid-19.

What does public health do? What challenges do departments face?

When comparing the expenditures in the region, Pender County has a higher per capita annual spending than New Hanover and Brunswick. Last year, for Pender it was $86 a person, the others were $58 and $56, respectively. Moser said one reason is the rural makeup of the county.

“Pender County is a provider shortage area. So we don’t have the number of dentists. We don’t have a number of primary care providers in our county that say New Hanover has," Moser said.

Moser said they have to be a safety-net provider because a lot of private providers tend to gravitate towards Hampstead and the coastal side of the county, so her department has to step in to fill gaps in service. For example, Moser said, they provide prenatal services to about a third of the babies that are born every year in the county.

But the mission of the region’s public health departments is similar. Environmental health takes up a large share of public health’s responsibility. Howard said they inspect between 15 and 20 institutions in the community like schools, daycares, hotels, and restaurants.

Moser said that in Pender County, health officials typically inspect more septic tanks and wells, in comparison to New Hanover County where there are more water and sewer infrastructure.

But finding the personnel to do those inspections, along with other public health positions, can be difficult, Moser said: “Aside from the fact that we have a lot of hard to recruit staff, such as your nurses, your nutritionists, and your environmental health specialists, it's sometimes difficult to recruit because of salary.”

All three directors are anticipating the explosive population growth that is to come to the region. In particular, Harrelson and Moser want to increase their programming and outreach to help residents 65 and older with chronic disease management. Harrelson said Brunswick County has already made significant investments in its senior centers.

What could increase funding for public health?

While Moser and Harrelson said they’re satisfied with the current level of public health spending, which is funded mainly by county property taxes, Howard said he’d like to see an increase in both federal and state funding for New Hanover’s programs.

“I think, if anything, we would wish to see a more steady stream of core funding for public health. So that number one, we can provide enhanced services, but also we can provide a stronger foundation of staffing and presence to respond to emergencies," Howard said.

There is proposed state legislation, House Bill 61, that would appropriate about $36 million to boost local health departments, which would help deal with a 200% increase in communicable diseases over the last decade.

NHC testing.jpg
Jared Hall
New Hanover County Flickr page
New Hanover County opening its first Covid-19 testing site in April 2020.

Howard said only about 5 to 10% of their funding for communicable diseases comes from the state and federal government, so he’s hoping that legislation will pass, being that they track around 80 reportable communicable diseases in the community, anywhere from Zika, tuberculosis, and STDs.

There’s also federal legislation that would appropriate funding for local health departments. It’s called the Public Health Infrastructure Saves Lives Act. The proposal is to provide $4.5 billion annually to state and local public health departments. The bill died in Congress last year but was reintroduced last month.

In the future, Howard would like state and federal funding to be less restrictive, so the county would have more discretion over where the money goes.

But, in the meantime, all three public health directors said they’re ready to return their focus to issues like tackling the opioid crisis and getting people back to their clinics for routine checkups, as the pandemic has co-opted much of public health’s resources.

“I don’t know if we’ll know what to do with ourselves, because it’s just go, go, go all the time with Covid, whether you’re doing contact tracing or you’re having large vaccination clinics, but I think we’ll get back into our normal routine eventually," said Moser.

Eric W. Peterson
New Hanover County Flickr page
A New Hanover County public health nurse receiving her first shot of the Moderna vaccine in December 2020. One of public health's main responsibilities right now is to run vaccination clinics.

Click here to view the 2010-2018 per capita analysis of 52 public health departments in North Carolina.

Thanks to N.C. Local News Workshop at Elon University for supporting this reporting.

Rachel is a graduate of UNCW's Master of Public Administration program, specializing in Urban and Regional Policy and Planning. She also received a Master of Education and two Bachelor of Arts degrees in Political Science and French Language & Literature from NC State University. She served as WHQR's News Fellow from 2017-2019. Contact her by email: rkeith@whqr.org or on Twitter @RachelKWHQR