Inaccuracy of official estimates of public health spending in the United States, 2000–2018

Objectives. To examine the accuracy of official estimates of governmental health spending in the United States. Methods. We coded approximately 2.7 million administrative spending records from 2000 to 2018 for public health activities according to a standardized Uniform Chart of Accounts produced by the Public Health Activities and Services Tracking project. The official US Public Health Activity estimate was recalculated using updated estimates from the data coding. Results. Although official estimates place governmental public health spending at more than $93 billion (2.5% of total spending on health), detailed examination of spending records from state governments shows that official estimates include substantial spending on individual health care services (e.g., behavioral health) and that actual spending on population-level public health activities is more likely between $35 billion and $64 billion (approximately 1.5% of total health spending). Conclusions. Clarity in understanding of public health spending is critical for characterizing its value proposition. Official estimates are likely tens of billions of dollars greater than actual spending. Public Health Implications. Precise and clear spending estimates are material for policymakers to accurately understand the effect of their resource allocation decisions.