Economic shocks and public health protections in US metropolitan areas.

Objectives: We examined public health system responses to economic shocks using longitudinal observations of public health activities implemented in US metropolitan areas from 1998 to 2012.

Methods: The National Longitudinal Survey of Public Health Systems collected data on the implementation of 20 core public health activities in a nationally representative cohort of 280 metropolitan areas in 1998, 2006, and 2012. We used generalized estimating equations to estimate how local economic shocks relate to the scope of activities implemented in communities, the mix of organizations performing them, and perceptions of the effectiveness of activities.

Results: Public health activities fell by nearly 5% in the average community between 2006 and 2012, with the bottom quintile of communities losing nearly 25% of their activities. Local public health delivery fell most sharply among communities experiencing the largest increases in unemployment and the largest reductions in governmental public health spending.

Conclusions: Federal resources and private sector contributions failed to avert reductions in local public health protections during the recession. New financing mechanisms may be necessary to ensure equitable public health protections during economic downturns.