This is the first in a series of several stories that will analyze funding and spending of health departments across the Border Belt.

For more than a decade, Columbus County women have had fewer and fewer affordable options for breast and cervical cancer screening, according to Elizabeth Kinlaw, an adult health nurse for the Columbus County Health Department. “There’s no help for them,” Kinlaw said. 

Kinlaw has been working for the health department for the last 18 years and has witnessed what she considers to be a  drastic decrease in funding. She used to have a lot of money to perform mammograms and pap smears, she claims, but that all shifted a decade ago.

Overall, funding for the Columbus County Health Department, which comes from federal, state and local sources, has plummeted. In 2010, the health department spent $7.7 million and received $7.4 million, according to an inflation-adjusted analysis of expenditure and revenue reports provided by the health department. By 2019, those numbers had dropped to $4.2 million and $2.4 million, respectively. That’s a 45% decrease in expenditures and a 68% decrease in revenues. 

“In public health, you learn how to do a lot with a lot less,” said Health Director Kim Smith.

Columbus County isn’t the only county facing this trend. It’s a nationwide problem, according to Adriane Casalotti, the chief of government and public affairs at the National Association of County and City Health Officials. This association, based in Washington, D.C., advocates for local health departments across the country. “This past decade, and even the decade before, we’ve really starved public health and in particular local health departments,” Casalotti said.

Casalotti noted that the downward trend started during the 2008 recession, when funding from the state and federal government sharply dropped. “Local health departments haven’t recovered,” she said. 

Since then, health departments have experienced a 16% decrease in funding, according to an analysis by Kaiser Health News. North Carolina ranks 14th from the bottom of the list, with average expenditures of only $72 per person in 2018. Locally, the Columbus County Health Department spent $76.79 per person in 2018.

“The decrease in funding for public health is a tragic reality of today’s life,” said Health Board Chair Dr. Randy Kirby. “The only thing that keeps public health going is the dedication of the public health staff, who does everything they can with a very limited budget and makes miracles happen.”

As one of those staff members, Kinlaw finds it hard to provide all of the necessary services, given the limited funding. “I have a certain amount that I can spend on each patient,” she said. “Then the patient has to be responsible.”

In 2018, Kinlaw had less than $17,000 to conduct all of her screenings for the year, according to inflation-adjusted expenditure reports. Eight years earlier, she had almost twice that amount. 

With these limited funds, the health department sometimes can’t pay for all the services a woman needs to detect breast or cervical cancer. Kinlaw argues that the Affordable Care Act, also known as Obamacare, has compounded this issue since 2010. “When [the federal government] started mandating insurances, that destroyed the program a lot,” Kinlaw said. “[Women] kind of fall in between the cracks because their insurance pays for part of it, but it doesn’t pay for the other.”

Kinlaw works with local doctors’ offices to set up payment plans for these women, but not all offices are willing to do so. “They want everything up front,” she said, which can total approximately $300. 

Casalotti has also seen a few instances of this insurance gap due to Obamacare. That leaves local health departments to pick up the slack. “They are the provider of last resort,” she said. “It’s really hard to recoup the cost.”

Overall, Casalotti argues that Obamacare has been helpful. “The Affordable Care Act put more of a focus on prevention,” she said. “That was the first time there was a dedicated stream [of funding] put toward public health.”

Different funding sources

The decrease in funding isn’t limited to breast and cervical cancer prevention. The health department as a whole has been dealing with the issue for the past decade, and it can’t cut every program to solve funding issues. “The state has not released us from any mandatory public health programs,” Director Smith said. “We still have to do certain programs and certain things.”

In 2010, the health department had 26 programs, according to expenditure reports. In 2017, the list had been whittled  down to 22. 

Some of these programs, however, are grant-related and are therefore not expected to continue forever. Certain grants only last a few years, and some grants weren’t available to health departments in 2010. “We were hot and heavy for a few years in there with grant money,” Smith said. “That way we don’t have to ask for local appropriations; it doesn’t fall on the taxpayers.”

Since 2010, the health department has seen a 17% increase in revenue from grants. Every other revenue source, however, has decreased, with state funding down by 39%, Medicaid by 68% and federal funding through the Women, Infants and Children program by 8%. “The amount that we have gotten from the state and/or federal government has decreased,” Smith said.

Smith added, however, that the trend didn’t apply to local appropriations from the Columbus County Board of Commissioners. “That amount has slowly crept up,” she said.

Ricky Bullard, chair of the Columbus County Board of Commissioners, hasn’t noticed the decreased funding from the state and federal government, but has noticed that the health department always needs money. “Every year at budget time, it seems there are more needs that are put on the table,” he said. “We try to meet those needs.”

In the last four years, however, the health department has comprised a smaller proportion of the county commissioners’ budget. In 2016, it was 9.8% of a $54 million budget, and in 2020 it was 7.6% of a $61 million budget, according to annual audit reports.

The declining share of the commissioners’ budget isn’t due to a lack of support for public health, according to Smith. “There are lots of needs from not just the health department but from other departments,” she said. “If we had more citizens who owned property and paid taxes, it would increase the money that our county government had to divvy up among the county offices.”

Bullard acknowledged that the county commissioners couldn’t provide everything the health department asked for, but said, “We’ll continue to do the best we can.”

The Columbus County Board of Commissioners recently proposed a 15.5% reduction in the health department’s budget for the 2021-2022 fiscal year. 

Population theory

Smith believes that the biggest factor in determining state funding is population size. “We are not a rich county,” she said. “We don’t have the number of people.”

The number of Columbus County residents has decreased from 58,000 to 55,800 in the last 10 years, according to data from the U.S. Census Bureau. However, that’s only a 3% decrease, compared to the 68% decrease in health department funding. 

In addition, the county is aging. Residents aged 65 and older make up 5% more of the population than they did a decade ago, according to data from the U.S. Census Bureau.

An aging population means costlier medical needs. On average, health care for individuals aged 65 and older costs over $11,000 per year, according to 2016 data from the U.S. Department of Health and Human Services. Care for individuals aged 45–64 costs less than half that amount, and care for individuals aged 18–44 costs a little more than a quarter of that amount. “The cost, both in money and in time and effort, really goes up as the population ages,” Kirby said. “People have more problems; people have more needs.”

There was no significant change in the racial makeup of the county during the last 10 years, according to U.S. Census data.

Other counties not as hard-hit

Some counties of similar size, however, haven’t seen as significant a decrease in health department funding in the last decade. For example, Halifax County, which has around 51,000 residents, has experienced smaller drops in population and health department funding over the past decade. 

Halifax County spent $7.7 million in 2010, which decreased by 19% over eight years, according to an analysis of 46 health departments conducted by students at the University of North Carolina. Health department per capita spending in Halifax County has also been consistently greater than that of Columbus County, with Halifax at $125 and Columbus at $76.79 in 2018. 

Lee and Lenoir counties have also seen smaller decreases in health department funding than Columbus County over the last decade, with funding in Lenoir County shrinking by 6.3% and in Lee County by 5.4%, according to the UNC analysis. 

These health departments, however, have had less money overall. In 2010, Lee County spent $57 per resident, and Lenoir County spent $63, according to the UNC data analysis. By 2018, Lee was at $52 and Lenoir at $62.

Columbus County spent $128 per person in 2010 and $76.79 in 2018.

Smith blames this sharper decrease in per-capita funding on Columbus County’s distance from growing coastal areas, which she believes receive more state and federal funding. “We don’t have sand,” she said. 

However, New Hanover and Brunswick counties both had a lower per-capita funding rate than Columbus County in 2010, with $89 and $72 respectively, according to data acquired by WHQR and shared with the Border Belt Independent. In 2018, they had similar per-capita rates to Columbus County, with New Hanover at $58 and Brunswick at $53. 

Lack of coverage theory

Casalotti, however, believes that the lack of media coverage has led to funding issues within many health departments. “The whole point of the work of health departments is to not be on the front pages,” she said. “They’re trying to prevent these problems from happening, but that makes it a lot harder to recognize the work they’re doing.”

The pandemic, however, has put health departments on the front page of media outlets across the world. “What COVID-19 has shown us is that we need strong public health beneath us,” she said. “When there’s a public health problem, it can grind all aspects of society into a stop.”

As a result, the Columbus County Health Department saw an increase in state and federal government funding in 2020 to help cover the costs stemming from the global pandemic.

By June 2020, the health department had collected around $335,000 more in revenue than in 2019. It also spent $490,000 more. “We got a little bit more money to spend on COVID-19 because we had more [cases] per population,” Smith said. 

Columbus County was hit hard by COVID-19, with a 15.8% positive testing rate and a 3% death rate at the pandemic’s height around December and January, according to the North Carolina Department of Health and Human Services. 

Casalotti called this influx of money due to the pandemic “boom and bust” funding. “When there’s a big crisis like this one, we see money flowing into the system,” she said. “The moment we move away from the front pages, those resources dry up.”

Casalotti predicted that COVID-19 funding will disappear, leaving health departments once again without enough money to provide essential services. They will lose staff, and they won’t have the manpower or funding to prevent an outbreak of some other virus or pathogen. “Public health problems don’t ever really go away,” Casalotti said. Without proper funding and staffing, “You don’t see where the cracks are until the pathogen comes along to take advantage of them.”

Little flexibility in transferring funds

Communicable disease programs help prevent those pathogens from getting through those cracks, but that is only possible with funding. In Columbus County, the communicable disease program has seen a 31% decrease in funding since 2010, according to expenditure reports. 

During the pandemic, Smith would have liked to transfer  money from different programs into the communicable disease program, but that’s not allowed. “It would be a whole lot easier if we had it all in one pot and could use it for whatever,” she said. 

Instead, the health department tries to predict future costs within each program. For example, if the family planning program has leftover funding, the health department will go ahead and use that leftover funding to purchase long-acting birth control for the next year. “We’re not wasting it; we’re going to use it,” Smith said. “That helps us from year to year, so we can provide the same level of service.”

Smith added that the health department does not return any funding to the state at the end of each budget year. “We do not waste money here,” she said.

A ‘vicious cycle’

The Columbus County Health Department’s limited per capita spending rate affects every aspect of the department, according to Smith. “To do more programs, I have to have more people, which costs more money,” she said. “That’s just your vicious cycle that you have in business.”

Kinlaw currently runs the breast and cervical cancer screening program by herself, conducting all the physicals and filling out all the paperwork. “If you don’t do your forms, you don’t get your money every month,” she said. “It’s a lot of red tape.”

If she had the funding, Kinlaw would be able to do more screenings that detect cancer. She caught one case last year.

This red tape isn’t unique to Kinlaw’s department. “The staff here always has the cost of their programs in mind,” Smith said.

If she had the money for it, Smith added that would also love to get out into the community and ask people what services they need. “I would hate to sit in a class about how to take care of your feet if my feet felt fine,” she said.

Even with progressively decreasing funding, Smith is proud of the work the health department has done over the years. “I think we do a wonderful job in being able to provide the services that we do for our citizens of Columbus County,” Smith said. “There’s never enough money, but we were able to get through it.”