The Changing Public Health Landscape: Findings from the 2014 Forces of Change Survey

By Sarah Newman, MPH, Research and Evaluation Analyst, NACCHO

NACCHO has released the 2014 Forces of Change survey containing new findings on the forces that affect change in our nation’s local health departments (LHDs). Economic forces, health reform, and health department accreditation are among the greatest contributors to change.


LHDs continue to experience budgetary challenges. Almost one-third of LHDs (28%) reported a lower budget in 2013 than the prior fiscal year and a similar proportion (29%) expect budget cuts to continue into the next fiscal year. LHDs also continue to lose jobs; since 2008, LHDs have collectively lost 48,300 jobs due to layoffs and attrition.

These budget realities and the choices LHDs are making about their role in the changing healthcare environment have affected the scale and scope of services LHDs provide. In 2013, LHDs reported more expansions than reductions in population-based services, such as population-based primary prevention services. With the exception of immunization (where LHDs reducing services greatly outnumber those expanding them), similar proportions of LHDs reported expansions and reductions in clinical services, such as chronic disease screening and treatment. Most LHDs (81%) are seeking to bolster revenue by increasingly billing public and private third-party payers for clinical services they provide.

Many previously uninsured people gained coverage under the Patient Protection and Affordable Care Act, but the limited role LHDs played in helping community members gain this coverage illustrates a missed opportunity to improve access to healthcare. Few LHDs (17%) served as navigators, a formal role responsible for enrolling people in health insurance programs available through a state or federal health exchange or marketplace. More LHDs assisted in an unofficial capacity, almost always without financial support.

Lastly, more LHDs have been formally engaged in the Public Health Accreditation Board’s voluntary accreditation program. In 2014, one percent of LHDs have achieved accreditation and 11 percent have submitted an application or Statement of Intent, nearly double the level of engagement measured in 2013. Accreditation in LHDs will provide the pathways to ensure accountability, consistency, better synergy between community needs and public health services, and improved performance.

Learn More

Findings from the survey are presented in five research briefs:
Local Health Department Budget Cuts and Job Losses
Changes in Local Health Department Services
Billing for Clinical Services
Role of Local Health Departments as Navigators
Local Health Department Accreditation

Visit to learn how economic and political forces are changing local public health.

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