While state governments raised more revenues than local governments in 2019, local governments' direct expenditures were larger than states' because localities often administer programs with funds transferred from state governments. In 2019, states transferred over $568 billion to local governments. This total includes indirect funds from the federal government, often referred to as pass-through grants. For example, the federal government sends elementary and secondary education funds to state governments, and then state governments transfer the money to local governments which spend the dollars on local education programs.
Many states and localities have anti-discrimination laws and agencies responsible for enforcing those laws. EEOC refers to these agencies as \"Fair Employment Practices Agencies (FEPAs).\" Through the use of \"work sharing agreements,\" EEOC and the FEPAs avoid duplication of effort while at the same time ensuring that a charging party's rights are protected under both federal and state law.
The Centers for Disease Control, the main assessment and epidemiologic unit for the nation, directly serves the population as well as providing technical assistance to states and localities. The National Center for Health Statistics within the Centers for Disease Control is the main authority for collecting, analyzing, and disseminating health data. The Agency for Toxic Substances and Disease Registry, also an assessment unit, focuses on environmentally related diseases. The National Institutes of Health, the primary research arm of the government, both conducts research and supports research projects across the nation. The Food and Drug Administration directly tests and assesses safety of food, drugs, and a wide variety of consumer goods and sets standards for safe use of these items. The Health Resources and Services Administration is primarily concerned with resources development and health manpower. The Alcohol, Drug Abuse, and Mental Health Administration concentrates on developing programs and setting standards in these areas. Both the Health Resources and Services Administration and the Alcohol, Drug Abuse, and Mental Health Administration establish and support health services through grants and contracts to state and local government agencies, private health care institutions, and individuals. They also act as coordinators and technical assistants to recipients of contracts and grants. Sometimes these agencies provide services, such as the Indian Health Service in the Health Resources and Services Administration, through which the government provides health care services to Native Americans and Eskimos. (Hanlon and Pickett, 1984)
The major portion of the federal government's health business is conducted through contracts and grants to states, localities, and private providers and organizations. The federal government acts through financing intergovernmental and interorganizational contracts to encourage various public health initiatives, convening participants around an issue, coordinating activities, and developing state and local provider contracts. In return for federal funds, states, localities, and private organizations must follow the federal standards and policies set in the contract. Thus in many programs, the federal government takes an oversight, policy-setting, and technical assistance role, rather than a direct provider role. Federal contracts can take the form of seed money for researching and developing new programs, such as Community Mental Health Centers, or they can be support for ongoing activities, such as the Early Periodic Screening, Detection, and Treatment Program. Contracts can be made with agencies to operate specific public health programs or to support general agency activities. Contracts can also be made with health care providers, such as nursing homes or home health agencies, for directly delivering personal health services. Contracts with local areas and providers may be operated through the states or be made directly with the local areas and private sector.
Most contracts to states and localities were initially offered as ''categorical\" grants, focusing on particular health issues or populations, for example, research training grants for education, nutrition information programs, substance abuse and mental health programs, and family planning programs. In the early 1980s, the federal administration grouped numerous categorical grants to states into four major \"block\" grants: one in preventive health, one in maternal and child health, one in primary care, and one in alcohol, drug abuse, and mental health. However, a number of categorical aid programs remain, both as grants to states and localities and to private providers. (Hanlon and Pickett, 1984)
The manner in which states allocate both finances and staff to different activities varies with the programs operated by the state agency, with the size of the state, with balance of responsibilities between states and localities, and with state traditions and priorities. As a group, the 46 state agencies reporting to the Public Health Foundation spent nearly $6 billion for their public health programs in 1984 (Public Health Foundation, 1986b). (This figure was for operation of public health agency programs only, and excludes Medicaid expenditures of states.) The expenditures per state ranged from $646 million in California to $13 million in Wyoming. (California is the most populous state in the country, and Wyoming is the least, save Alaska.) (U.S. Department of Commerce, 1986) Expenditures vary both with size of population and with the scope of responsibilities carried out by state agencies. Public health agency dollars per citizen range from the low 20s to the high 20s between states. (U.S. Department of Commerce, 1986)
Environmental programs are mainly handled by the Environmental Protection Agency and by the Agricultural Department. These agencies conduct assessment activities, develop policies and standards, provide direct services and technical assistance to states and localities, and conduct research. The Environmental Protection Agency has programs in air pollution and water pollution control, hazardous waste cleanup, control of pesticides, radiation protection, and research. (Haskell and Price, 1973) Some of these programs are direct federal activities, and some provide assistance to state environmental departments and state health agencies. The Agricultural Department has services for food safety and inspection, sanitation, and assessment of both plant and animal diseases. These services are predominantly federally run. The federal government spent more than $3.5 billion on environmental programs in 1986. (Executive Office of the President, Office of Management and Budget, 1987)
The majority of federal mental health programs are sponsored by the Public Health Service in the Alcohol, Drug Abuse, and Mental Health Administration. This administration predominantly conducts its programs through grants and contracts to states, localities, and private organizations. Some additional mental health programs are conducted through other departments, for example, Department of Education programs for the handicapped. The federal government is also involved in directly financing mental health care through the Medicare and Medicaid programs and in directly providing mental health care through the operation of a mental health hospital. The federal government spent more than $3 billion on mental health programs and care in 1983 in contracts and grants and in financing care for individuals. (Mazade et al., 1985a)
Several new elements have been incorporated into the 2017 guidelines. First, to support updated recommendations on the use of NPIs, the latest scientific evidence available since the influenza A (H1N1)pdm09 pandemic has been added. Second, a summary of lessons learned from the 2009 H1N1 pandemic response is presented to underscore the importance of broad and flexible prepandemic planning. Third, a new section on community engagement has been included to highlight that the timely and effective use of NPIs depends on community acceptance and active participation. Fourth, to provide new or updated pandemic assessment and planning tools, the novel influenza virus pandemic intervals tool, the Influenza Risk Assessment Tool, the Pandemic Severity Assessment Framework, and a set of prepandemic planning scenarios are described. Finally, to facilitate implementation of the updated guidelines and to assist states and localities with prepandemic planning and decision-making, this report links to six supplemental prepandemic NPI planning guides for different community settings that are available online ( -interventions).
The decision regarding whether and when to recommend additional NPIs is another component ( Table 3). State and local public health departments might use certain influenza surveillance indicators to help decide when to consider implementing NPIs such as school closures and dismissals and other social distancing measures in schools, workplaces, and public settings during an influenza pandemic. The choice of influenza surveillance indicators might differ among states and localities, depending on the availability and capacity of their public health resources. Examples of possible influenza surveillance indicators include additional patient visits to health care providers for influenza-like illness (ILI) and increased geographic spread of influenza within a state. Indicators for school closures and dismissals might include increased school absenteeism rates or the earliest laboratory-confirmed influenza cases among students, teachers, or staff members. Indicators that might help confirm that NPI implementation should continue include increased influenza-associated hospitalizations or increases in adult or pediatric deaths attributed to influenza. Additional information about NPI prepandemic planning is available (s