As federal and state governments progressively diminish their roles in funding and supporting public health, hospitals and health systems will increasingly bear responsibility for public health functions—or the consequences for their absence. Failure to assume this responsibility will inevitably lead to deteriorating community health and worsening financial strain due to an increasing patient population that is both sicker and less able to afford care. It is really a Hobson’s choice for health systems, where only one option is truly an option, even though the choice to do nothing appears available—and is the one that some may opt to take.
The numbers are staggering. According to the Trust for America’s Health 2024 report, only 3.4% of the nation’s $4.5 trillion in health expenditures went to public health and prevention—an actual decline from the already inadequate 4.4% cited two years prior. Since 2010, per capita federal funding for public health through the Centers for Disease Control and Prevention and the Health Resources and Services Administration has increased only modestly—from $27.49 in fiscal year 2010 to $39.56 in fiscal year 2023—and when adjusted for inflation and public health needs, the purchasing power of many local and state health departments has declined.
State-level disinvestment compounds the problem. From 2010 to 2021, state public health budgets decreased in 25 states when adjusted for inflation. Local public health departments, especially those serving rural or economically disadvantaged areas, have been forced to reduce services or staff, further diminishing the reach of preventive interventions. Chronic underfunding has led to a brittle public health infrastructure ill-equipped to manage ongoing challenges like opioid use disorder, mental health crises, chronic disease prevention and preparedness for future pandemics.
These trends signal even greater pressures on health system leaders, driven by declining public health. Without sufficient preventive and community-based interventions, health systems will face rising numbers of chronically ill patients, escalating healthcare costs and increasingly uncompensated care burdens. It is a downward spiral that will be difficult to break, one that will require not only additional resources but different strategies and skills to address.
Moreover, the cost of this neglect is not just clinical or financial—it is societal. A weaker public health infrastructure undermines trust in healthcare, erodes community resilience and leaves vulnerable populations behind. Emergency departments are already flooded with preventable crises—untreated diabetes, uncontrolled hypertension and avoidable infections—often in patients with no primary care connection or insurance coverage. For health systems, this means higher utilization of high-cost services and an even greater strain on overworked staff and underfunded safety-net programs.
However, there is reason for optimism. Throughout the United States, proactive hospitals and health systems are already implementing strategies to address the social determinants of health that profoundly impact patient outcomes. By integrating interventions focused on housing stability, adequate nutrition, reliable transportation and education, these healthcare organizations are effectively reducing preventable hospital visits and improving overall community well-being. Models such as community-based care coordination, investment in upstream public health initiatives, and hospital-sponsored housing and food security programs are demonstrating measurable returns—not only in improved health outcomes but in financial sustainability.
Importantly, some systems are also partnering with public health agencies and community-based organizations to codevelop interventions rather than duplicating services. These collaborations can stretch limited resources further, build trust in marginalized communities and help rebuild the fabric of public health from the ground up. Forward-thinking executives recognize that a stable, resilient and healthy community is the best strategy for long-term operational success.
Ultimately, health systems must see themselves not as passive recipients of public health failure, but as co-stewards of population health. That means embracing new roles, aligning missions with community outcomes, and advocating fiercely for renewed public investment. The moral imperative is clear—and so is the business case.
By taking proactive steps now—such as integrating social needs assessments into routine care, forging community partnerships to address critical needs and advocating for sustainable public health funding—health systems can significantly mitigate the negative impacts of diminished governmental support.
Hospital administrators have a clear choice: They can actively expand their role to include preventive public health measures or face increased operational and financial challenges from a sicker, economically disadvantaged patient population. Embracing these comprehensive strategies now is not only beneficial but essential to the future viability and effectiveness of healthcare delivery.
Eric W. Ford, PhD, is editor, Journal of Healthcare Management.
Editor’s Note: This content has been excerpted from “How Hospitals Can Respond to Declining Support for Public Health,” Journal of Healthcare Management, vol. 70, no. 5.