The Association of COVID-19 Infection and Vaccination Rates in Florida.

OBJECTIVE: This study investigates the association of COVID-19 infection and vaccination rates with 2020 presidential election voting preference in Florida counties and the moderating role of age, race, ethnicity, and other community characteristics. METHODS: Florida county COVID-19 infection and vaccination counts through September 2021 were supplemented with socioeconomic characteristics and 2020 presidential election results. Poisson regression measured the association of infection and vaccination rates with county political preferences, race, ethnicity, and other county demographic and economic characteristics. For models of April through September 2021 infection rates, the same county characteristics were assessed alongside county vaccination levels. RESULTS: Each 1% increase in county full vaccination rates was associated with 82.47 fewer infections per 100 000 during the span of April to September 2021. Vaccination rate was the largest and most statistically significant determinant of vaccine era infections. Each 1% increase in the county share of votes for the 2020 Republican presidential candidate was associated with 109.7 more COVID-19 infections per 100 000 through March 2021 and a 0.546% decrease in county vaccination rates through September 2021. CONCLUSIONS: At the county level, COVID-19 vaccination rates are associated with infection rates, with a higher county population proportion of fully vaccinated associated with fewer infections per 100 000. County political preference in the 2020 presidential election is significantly associated with county-level COVID-19 infection and vaccination rates.

COVID-19 Infections and Mortality in Florida Counties: Roles of Race, Ethnicity, Segregation, and 2020 Election Results.

PURPOSE: This study investigates the association of racial and ethnic composition, segregation, and 2020 presidential election voting results with COVID-19 infections and deaths in Florida counties. METHODS: Florida county COVID-19 infection and death counts reported through March 2021 were supplemented with socioeconomic characteristics and 2020 presidential results to form the dataset employed in this ecological study. Poisson regression analysis measured the association of infection and mortality rates with county demographic and economic characteristics, then assessed the moderating role of county political preferences. RESULTS: Counties with higher proportions of Black residents experience disproportionately higher COVID-19 infection and mortality rates. Disparities are further inflated in counties with larger Republican vote shares. That voting effect extends to Hispanic population proportions and segregation, both of which are associated with higher COVID-19 infection and mortality rates in more Republican-leaning counties. CONCLUSIONS: Communities challenged by pre-existing health disparities, segregation, and economic hardship before the pandemic bear disproportionate risk of COVID-19 infection and mortality. Factors associated with voter preference for the 2020 Republican presidential candidate compound those problems, worsening consequences for all county residents, suggesting deeper structural health challenges.

Association of Age-Specific 2020 Florida COVID-19 Rates With Population Age Distribution and Presidential Preference.

OBJECTIVE: To assess whether county age distribution is associated with age-specific COVID-19 infection, emergency department, hospitalization, and mortality rates. DESIGN: Florida's 2020 COVID-19 cases are summarized into age-specific county rates and supplemented with socioeconomic and demographic characteristics and 2020 presidential voting results to assess the association of population age structure and political choices with age-specific COVID-19 infection, emergency, hospitalization, and mortality rates. RESULTS: Younger counties experienced higher under-25 infection rates, as well as higher over-64 infection, emergency, and hospitalization rates. Older counties experienced reduced infection rates for all ages and decreased over-64 emergency and hospitalization rates. Trump's vote share was associated with higher infection rates for all and higher over-64 emergency, hospitalization, and mortality rates. CONCLUSIONS: Younger counties experience higher COVID-19 infection rates for all residents, with elevated morbidity risks among seniors. Older counties had lower COVID-19 infection, emergency, and hospitalization rates. Age-specific messaging may help slow pandemic spread.

Maternal Mortality and Public Health Programs: Evidence from Florida.

Policy Points US maternal mortality rates (MMRs) display considerable racial disparities and exceed those of other developed countries. While worldwide MMRs have dropped sharply since the 1990s, the US MMR appears to be rising. We provide strong evidence of the effectiveness of pregnancy-related public health spending on improvements in maternal health. Using longitudinal data from Florida counties, we found that spending on public health significantly reduced the MMR among black mothers and narrowed black-white outcome disparities. Each 10% increase in pregnancy-related public health expenditures was associated with a 13.5% decline in MMR among blacks and a 20.0% reduction in black-white disparities. CONTEXT: Maternal mortality rates in the United States exceed those of other developed countries. Moreover, these rates show considerable racial disparities, in which black mothers are at three to four times the risk compared with their white counterparts. With more than half of all maternal deaths deemed to be preventable, public health interventions have the potential to improve maternal health along with other pregnancy outcomes. This rigorous longitudinal study examines the impact of a package of pregnancy-related public health programs on maternal mortality rates. METHODS: We analyzed administrative data on pregnancy-related public health expenditures, maternal mortality rates, and sociodemographic factors from all 67 Florida counties between 2001 and 2014. Florida provides consistent counts of maternal deaths for the entire period of this analysis. We estimated both fixed-effects ordinary least squares regressions (OLS) and generalized method of moments (GMM) models. GMM enabled us to identify the impact of public health expenditures on maternal mortality rates while also addressing both potential endogeneity and serial correlation problems. We also provide a series of robustness and falsification tests. FINDINGS: Overall, a 10% increase in targeted public health expenditures led to a weakly significant decline in overall maternal mortality rates of 3.9%. The estimated effect for white mothers was not statistically significant. However, we found statistically significant improvements for black mothers. Specifically, a 10% increase in pregnancy-related public health spending led to a 13.5% decline in maternal mortality rates among black mothers and a 20.0% reduction in the black-white maternal mortality gap. CONCLUSIONS: Our analysis provides strong evidence of the effectiveness of public health programs in reducing maternal mortality rates and addressing racial disparities.

Diversity improves performance and outcomes.

BACKGROUND: Research on the effects of increasing workplace diversity has grown substantially. Unfortunately, little is focused on the healthcare industry, leaving organizations to make decisions based on conflicting findings regarding the association of diversity with quality and financial outcomes. To help improve the evidence-based research, this umbrella review summarizes diversity research specific to healthcare. We also look at studies focused on professional skills relevant to healthcare. The goal is to assess the association between diversity, innovation, patient health outcomes, and financial performance. METHODS: Medical and business research indices were searched for diversity studies published since 1999. Only meta-analyses and large-scale studies relating diversity to a financial or quality outcome were included. The research also had to include the healthcare industry or involve a related skill, such as innovation, communication and risk assessment. RESULTS: Most of the sixteen reviews matching inclusion criteria demonstrated positive associations between diversity, quality and financial performance. Healthcare studies showed patients generally fare better when care was provided by more diverse teams. Professional skills-focused studies generally find improvements to innovation, team communications and improved risk assessment. Financial performance also improved with increased diversity. A diversity-friendly environment was often identified as a key to avoiding frictions that come with change. CONCLUSIONS: Diversity can help organizations improve both patient care quality and financial results. Return on investments in diversity can be maximized when guided deliberately by existing evidence. Future studies set in the healthcare industry, will help leaders better estimate diversity-related benefits in the context of improved health outcomes, productivity and revenue streams, as well as the most efficient paths to achieve these goals.

Effectiveness of public health spending on infant mortality in Florida, 2001-2014.

Studies investigating the effectiveness of public health spending typically face two major challenges. One is the lack of data on individual program spending, which restricts researchers to rely on aggregate expenditures. The other is the failure to address issues of endogeneity and serial correlation between health outcomes and spending. In this study, we demonstrate that the use of specific spending items as opposed to overall spending, combined with Generalized Method of Moments estimation techniques can do a far better job in revealing the effectiveness of public health services on health outcomes. As an example, we consider the effects of infant-related public health programs on infant mortality rates. Focus on programs expressly related to maternal and infant health was made possible by a unique longitudinal dataset from the Florida Department of Health containing information for all 67 Florida counties spanning 2001 through 2014. Our empirical methodology, by addressing potential endogeneity issues along with serial correlation, allows us to estimate the causal impact of specific public health investments in maternal and infant-related programs on infant mortality. We find that a 10 percent increase in targeted public health spending per infant leads to a 2.07 percent decrease in infant mortality rates. We also find that targeted spending may be more effective in reducing infant mortality among blacks than among whites. The use of targeted spending data along with the Generalized Method of Moments technique can provide stronger evidence to guide future resource allocation and policy decisions in public health.

Opportunities for Prevention: Assessing Where Low-Income Patients Seek Care for Preventable Coronary Artery Disease.

The Affordable Care Act has many aspects that are aimed at improving health care for all Americans, including mandated insurance coverage for individuals, as well as required community health needs assessments (CHNAs), and reporting of investments in community benefit by nonprofit hospitals in order to maintain tax exemptions. Although millions of Americans have gained access to health insurance, many--often the most vulnerable--remain uninsured, and will continue to depend on hospital community benefits for care. Understanding where patients go for care can assist hospitals and communities to develop their CHNA and implementation plans in order to focus resources where the need for prevention is greatest. This study evaluated patient care-seeking behavior among patients with coronary artery disease (CAD) in Florida in 2008--analyzed in 2013--to assess whether low-income patients accessed specific safety net hospitals for treatment or received care from hospitals that were geographically closer to their residence. This study found evidence that low-income patients went to hospitals that treated more low-income patients, regardless of where they lived. The findings demonstrate that hospitals-especially public safety net hospitals with a tradition of treating low-income patients suffering from CAD-should focus prevention activities where low-income patients reside.

Economies of scale in the production of public health services: an analysis of local health districts in Florida.

OBJECTIVES: We examined the existence and the extent of scale and scope economies in the delivery of public health services. We also tested the strength of agency, population, and community characteristics that moderate scale and scope economies. METHODS: We collected service count and cost data for all Florida local health districts for 2008 and 2010, complemented with data on agency, population, and community characteristics. Using translog cost functions, we built models of operating efficiencies for 5 core public health activities: communicable disease surveillance, chronic disease prevention, food hygiene, on-site sewage treatment, and vital records. RESULTS: Economies of scale were found in most activities, with cost per unit decreasing as volume increased. The models did not, however, identify meaningful economies of scope. CONCLUSIONS: Consolidation or regionalization might lower cost per unit for select public health activities. This could free up resources for use in other areas, further improving the public's health.

Public health capacity in the provision of health care services.

In this paper, we assess the capacity of Florida's public health departments. We achieve this by using bootstrapped data envelopment analysis (DEA) applied to Johansen's definition of capacity utilization. Our purpose in this paper is to measure if there is, theoretically, enough excess capacity available to handle a possible surge in the demand for primary care services especially after the implementation of the Affordable Care Act that includes provisions for expanded public health services. We measure subunit service availability using a comprehensive data source available for all 67 county health departments in the provision of diagnostic care and primary health care. In this research we aim to address two related research questions. First, we structure our analysis so as to fix budgets. This is based on the assumption that State spending on social and health services could be limited, but patient needs are not. Our second research question is that, given the dearth of primary care providers in Florida if budgets are allowed to vary is there enough medical labor to provide care to clients. Using a non-parametric approach, we also apply bootstrapping to the concept of plant capacity which adds to the productivity research. To preview our findings, we report that there exists excess plant capacity for patient treatment and care, but question whether resources may be better suited for more traditional types of public health services.

Setting budgets and priorities at state health agencies.

CONTEXT: State health departments across the country are responsible for assuring and improving the health of the public, and yet financial constraints grow only more acute, and resource allocation decisions become even more challenging. Little empirical evidence exists regarding how officials working in state health departments make these tough allocation decisions. DESIGN: Through a mixed-methods process, we attempted to address this gap in knowledge and characterize issues of resource allocation at state health agencies (SHAs). First, we conducted 45 semistructured interviews across 6 states. Next, a Web-based survey was sent to 355 public health leaders within all states and District of Columbia. In total, 207 leaders responded to the survey (66% response rate). PARTICIPANTS: Leaders of SHAs. RESULTS: The data suggest that state public health leaders are highly consultative internally while making resource allocation decisions, but they also frequently engage with the governor's office and the legislature-much more so at the executive level than at the division director level. Respondents reported that increasing and decreasing funding for certain activities occur frequently and have a moderate impact on the agency or division budget. Agencies continue to "thin the soup," or prefer cutting broadly to cutting deeply. CONCLUSIONS: Public health leaders report facing significant tradeoffs in the course of priority-setting. The authorizing environment continues to force public health leaders to make challenging tradeoffs between unmet need and political considerations, and among vulnerable groups.

Budget- and priority-setting criteria at state health agencies in times of austerity: a mixed-methods study.

OBJECTIVES: We examined critical budget and priority criteria for state health agencies to identify likely decision-making factors, pressures, and opportunities in times of austerity. METHODS: We have presented findings from a 2-stage, mixed-methods study with state public health leaders regarding public health budget- and priority-setting processes. In stage 1, we conducted hour-long interviews in 2011 with 45 health agency executive and division or bureau leaders from 6 states. Stage 2 was an online survey of 207 executive and division or bureau leaders from all state health agencies (66% response rate). RESULTS: Respondents identified 5 key criteria: whether a program was viewed as "mission critical," the seriousness of the consequences of not funding the program, financing considerations, external directives and mandates, and the magnitude of the problem the program addressed. CONCLUSIONS: We have presented empirical findings on criteria used in state health agency budgetary decision-making. These criteria suggested a focus and interest on core public health and the largest public health problems with the most serious ramifications.

How the choice of issuing authority affects hospital debt financing costs.

All other things being equal, bonds issued by statewide authorities have lower yields than bonds issued by local authorities. However, lower yields may be offset by higher issuance costs for statewide authorities, as reflected in the true interest cost. Higher issuance costs may provide benefits for investors and for issuing hospitals.

Public health services and systems research: current state of finance research.

There is a growing recognition that the US public health system should strive for efficiency-that it should determine the optimal ways to utilize limited resources to improve and protect public health. The field of public health finance research is a critical part of efforts to understand the most efficient ways to use resources. This article discusses the current state of public health finance research through a review of public health finance literature, chronicles important lessons learned from public health finance research to date, discusses the challenges faced by those seeking to conduct financial research on the public health system, and discusses the role of public health finance research in relation to the broader endeavor of Public Health Services and Systems Research.

Resource and cost adjustment in the design of allocation funding formulas in public health programs.

CONTEXT: Multiple federal public health programs use funding formulas to allocate funds to states. OBJECTIVE: To characterize the effects of adjusting formula-based allocations for differences among states in the cost of implementing programs, the potential for generating in-state resources, and income disparities, which might be associated with disease risk. SETTING: Fifty US states and the District of Columbia. INTERVENTION: Formula-based funding allocations to states for 4 representative federal public health programs were adjusted using indicators of cost (average salaries), potential within-state revenues (per-capita income, the Federal Medical Assistance Percentage, per-capita aggregate home values), and income disparities (Theil index). MAIN OUTCOME: Percentage of allocation shifted by adjustment, the number of states and the percentage of US population living in states with a more than 20% increase or decrease in funding, maximum percentage increase or decrease in funding. RESULTS: Each adjustor had a comparable impact on allocations across the 4 program allocations examined. Approximately 2% to 8% of total allocations were shifted, with adjustments for variations in income disparity and housing values having the least and greatest effects, respectively. The salary cost and per-capita income adjustors were inversely correlated and had offsetting effects on allocations. With the exception of the housing values adjustment, fewer than 10 states had more than 20% increases or decreases in allocations, and less than 10% of the US population lived in such states. CONCLUSIONS: Selection of adjustors for formula-based funding allocations should consider the impacts of different adjustments, correlations between adjustors and other data elements in funding formulas, and the relationship of formula inputs to program objectives.

Funding formulas for public health allocations: federal and state strategies.

Public health funding formulas have received less scrutiny than those used in other government sectors, particularly health services and public health insurance. We surveyed states about their use of funding formulas for specific public health activities; sources of funding; formula attributes; formula development; and assessments of political and policy considerations. Results show that the use of funding formulas is positively correlated with the number of local health departments and with the percentage of public health funding provided by the federal government. States use a variety of allocative strategies but most commonly employ a "base-plus" distribution. Resulting distributions are more disproportionate than per capita or per-person-in-poverty allotments, an effect that increases as the proportion of total funding dedicated to equal minimum allotments increases.

Reference allocations and use of a disparity measure to inform the design of allocation funding formulas in public health programs.

Funding formulas are commonly used by federal agencies to allocate program funds to states. As one approach to evaluating differences in allocations resulting from alternative formula calculations, we propose the use of a measure derived from the Gini index to summarize differences in allocations relative to 2 referent allocations: one based on equal per-capita funding across states and another based on equal funding per person living in poverty, which we define as the "proportionality of allocation" (PA). These referents reflect underlying values that often shape formula-based allocations for public health programs. The size of state populations serves as a general proxy for the amount of funding needed to support programs across states. While the size of state populations living in poverty is correlated with overall population size, allocations based on states' shares of the national population living in poverty reflect variations in funding need shaped by the association between poverty and multiple adverse health outcomes. The PA measure is a summary of the degree of dispersion in state-specific allocations relative to the referent allocations and provides a quick assessment of the impact of selecting alternative funding formula designs. We illustrate the PA values by adjusting a sample allocation, using various measures of the salary costs and in-state wealth, which might modulate states' needs for federal funding.

Assessing the level of public health partner spending using the funding formula analysis tool.

Public health services are delivered through a variety of organizations. Traditional accounting of public health expenditures typically captures only spending by government agencies. New Hampshire collected information from public health partners, such as community centers that host smoking cessation classes or health education done by Girls, Inc. This study compares the new data to spending by government agencies, focusing on breakdowns by fund source and service categories. Expanded funds secured by these partners account for a 42% of all local public health spending, and they spent 4 times more than government agencies on promoting healthy behavior. The funding formula analysis tool revealed that these partners spent in ways that would be politically difficult to achieve. In an era of declining budgets, an understanding of public health's partners is increasingly vital.

The impact of competition among health care financing authorities on market yields and issuer interest expenses.

The main source of capital for non-for-profit health care organizations is tax-exempt municipal bonds. The tax-exempt nature of this debt requires that they be issued through financing authorities, which are run by, or affiliated with, state or local government agencies. In some states, all tax-exempt health care bonds must be issued through a single financing authority, but in other states the issuing health care organization has a choice of multiple authorities. Using a Herfindahl index of issuer concentration, prior research has found that greater competition among authorities results in lower interest costs to the issuing health care organization. We pick up where this earlier study left off, examining the links between authority competition, the interest expenses to the issuer, and the yield to the market investor. Although our analysis of all hospital bonds issued between 1994 and 2002 corroborates earlier findings with regard to interest expenses to the issuing health care organization, we also find market yield is lower for statewide authorities where issuer concentration is lower. Thus, authority competition is good from the issuers' point of view, but holds no favor in the investors' eyes. On the other hand, the lower market yield associated with statewide authorities does not make its way down to the issuer in the form of lower interest costs. To help sort through this paradox, we explore our findings through interviews of executives in state issuing authorities.

Social efficiency of hospital care delivery: frontier analysis from the consumer's perspective.

The efficiency of hospital services and patients' access to hospitals are both important health care policy issues. In the past, research has relied on studying these topics separately. In this article, we measure both efficiency and access at the same time using data envelopment analysis (DEA). By including both the technically efficient use of resources, as well as the patients' travel distances, we found increases in social efficiency when patients' travel distances were taken into account. When compared with patients with nonurgent conditions, we found that patients suffering from conditions requiring urgent attention were treated at closer hospitals, increasing the social efficiency. Insurance coverage and hospital ownership were also examined. Our findings corroborated past literature in the hospital and travel distance literature and set out a framework for future research. Perhaps most important, we demonstrate the techniques needed to incorporate broader measures of social costs into studies of hospital efficiency.