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To assess the state of the public health system in the United States, KHN, also known as Kaiser Health News, and The Associated Press analyzed data on government spending and staffing at national, state and local levels.

What reporters found was a mix of survey and budget data, each measuring a slightly different concept of “public health.

Some datasets track only state public health systems, not agencies that operate at a county, city or regional level. Other data, including some from the U.S. Census Bureau, covers spending on all nonhospital health care. Public health efforts are mixed in with the costs of providing local medical transportation, running community clinics, and offering mental health services.

The lack of comprehensive data specifically about public health makes assessing community programs, agencies and staffing levels difficult, experts say. Public health information is scattered and can’t be easily compared, unlike data about hospitals and medical treatment, according to Betty Bekemeier, a public health systems researcher and professor at the University of Washington. She is seeking to fix this as the leader of a multistate effort to standardize local health department spending data.

“We will not be able to improve our systems if we don’t have a better idea of how it works,” she said.

KHN and AP calculated 2016-18 average annual state spending directly on public health initiatives using the State Health Expenditure Dataset. To create the dataset, a team of researchers encoded data from the Census Bureau’s “ Annual Survey of State Government Finances,” isolating public health costs to get the clearest sense of what governments spend only on public health efforts.

The data includes spending by all state agencies and their transfers to local governments. To account for inflation for this and all spending data, KHN and the AP adjusted to 2019 dollars using a price deflator from the Bureau of Economic Analysis targeted toward government expenses.

A decade of data on state public health agencies’ expenditures and full-time equivalent staffing came from the Association of State and Territorial Health Officials. The data was reported directly by the state public health agencies through a national survey.

When creating national percentage change estimates, reporters excluded a handful of states missing comparable spending or staffing data.

The analysis included census finance data from state and local governments to compare spending on nonhospital health with other priorities such as policing and highway construction and maintenance.

At the local level, the National Association of County and City Health Officials’ “ National Profile Study ” surveys local health departments every three years and weights answers to account for nonresponse.

Beyond that, some states collect local health department spending and staffing data. Reporters used detailed data on local health departments in Florida, Minnesota, Missouri, North Carolina, Ohio and Washington — along with census population estimates — to examine per capita trends over time.

Finally, AP statehouse reporters posed an identical set of questions to states to get a sense of recent and upcoming budget and staffing changes to state public health departments. The AP gathered responses from 43 states.


Contact AP’s global investigative team at


This story is a collaboration between The Associated Press and KHN (Kaiser Health News), which is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation) that is not affiliated with Kaiser Permanente.

Copyright 2020 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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Turkish Parliament Passes Disputed Bar Associations Law

ANKARA (Reuters) - Turkey's parliament passed a law on Saturday on changing the structure of bar associations, a move that lawyers argue will further undermine judicial independence in a country where they say the judiciary is already in disarray.

Thousands of lawyers have protested in Istanbul, Ankara and other cities against the plan, saying it aims to silence some of the few institutions still speaking out against the government's record on rule of law and human rights.

The legislation allows multiple bar associations to be formed in each province, in place of the current system where each province has a single association, diluting the institutions' power.

A lawmaker for President Tayyip Erdogan's AK Party, Cahit Ozkan, said last week the law was needed because bar associations were no longer able to function properly following a 13-fold increase in the number of lawyers in Turkey since the previous law came into effect.

Opponents say it will strengthen small provincial bars at the expense of the large associations in the main cities. The larger associations currently predominate and are frequently critical of the government.

These associations say the judicial system has descended into chaos in recent years with lawyers jailed, defences muzzled and confidence in judges and prosecutors destroyed.

The law was passed with 251 votes in favour in the 600-seat parliament, with only 417 MPs voting. The AK Party has 291 seats in the assembly, while its nationalist MHP allies have 49 seats.

The legislation "appears calculated to divide the legal profession along political lines and diminish the biggest bar associations' role as human rights watchdogs," Human Rights Watch and the International Commission of Jurists said.

Muharrem Erkek, deputy leader of the main opposition Republican People's Party, said the new law would erode and polarise the legal profession.

"Their aim is to create partisan bar associations. If you weaken the bars, if you divide them, the citizens will suffer harm," he said shortly before parliament began debating the bill on Wednesday.

(Reporting by Daren Butler and Ece Toksabay; Editing by Frances Kerry)

Copyright 2020 Thomson Reuters.

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