COLUMBIA — Columbia is a staple in rankings of the best places to live, work, go to school, start a business or retire. Livability, a website that ranks U.S. cities using data about their economies, education and health care, ranked Columbia 46th on its Top 100 Places to Live in 2016, up from 50th in 2015.

Wider Boone County does well in primarily health-based rankings. According to the University of Wisconsin Population Health Institute, the county ranks 14th in overall health of the 115 counties in Missouri.

Part of that is because of public health policies. Residents of Boone County have it pretty good in that category, said Linda Cooperstock, immediate past president of the Missouri Public Health Association and former public health planner for the Boone County Health Department. 

For example:

  • Tobacco use is regulated. Its use is prohibited in all public places, as is its sale to people under 21 in Columbia.
  • Flu vaccines are available to Columbia elementary and middle school children in 19 schools through funding and starter grants obtained by MU's Women's and Children's Hospital and the David B. Lichtenstein Foundation, one of the health department's main sources of additional funding.
  • Improvements of streets and sidewalks, which Cooperstock credits to the city's Planning and Zoning Commission, encourage safe walking and biking. Boone County also has numerous parks and trails. All of these encourage physical activity, one of the most effective ways to prevent disease and stay healthy.
  • Both Columbia and Ashland have programs that promote community gardening
  • A lack of industries that pollute air and water also affect Boone County's bottom line in public health.

“In Columbia and Boone County, we enjoy a great deal of support for public health,” said Scott Clardy, assistant director of the Columbia/Boone County Department of Public Health and Human Services. “Our policymakers — those who control the budget — and our public support public health activities in this community, and that’s not something that every health department across the state has the fortune of having.”

From 2003-2013 (the most recent data available), Boone County had significantly lower rates of ER visits, hospitalizations and deaths from chronic diseases — heart disease, stroke and all types of cancer — than Missouri did as a whole. Though in many cases both show a statistically significant decrease over this 10-year period, Boone County's rate is consistently much lower than Missouri's.

During the 2014-2015 fiscal year, the Columbia/Boone County Department of Public Health and Human Services budgeted nearly $45 per resident on public health programs and services. This is far from the most spent in a single Missouri county, but it is enough to implement effective public health programs because Boone County does not have widespread health issues. Poorer counties tend to have poorer overall health.

But Boone County is not an island. Underfunding of public health in the state does have implications for all Missourians, since low funding in large portions of the state can compel people to seek public health services in places with more funding, such as Boone County. This could result in services, especially clinical ones, being spread too thin.

That's why the public health funding struggle in Missouri is all the more worrisome. In fiscal year 2014-2015, Missouri ranked 50th out of 51 (including Washington, D.C.) in the U.S. in public health funding, with the state legislature budgeting only $5.90 per resident from its general revenue. The national median for state spending was $33.50.

'Tremendously underfunded'

Each year, state legislators decide how much money from the state’s general revenue goes toward Aid to Local Public Health. The Missouri Department of Health and Senior Services then distributes this money among local health agencies based in part on population, and local health agencies decide how to spend it. The majority of additional funding comes from grants, fees charged for services and local tax dollars appropriated to public health spending.

The Boone County Health Department also has contracts with the state to implement specific programs like inspections of childcare centers and emergency response training.

This means some agencies end up with more funding than others. Smaller, more rural agencies often do not have the resources to seek out significant additional funding, so they must depend more heavily on state funds.

The problem? Less than 1 percent of local agencies’ budgets now come from the state’s general revenue.

Clardy worked at the state level for 24 years. He started as a chemist and ended as deputy director of the Division of Community and Public Health. Clardy began as assistant director at the Boone County Health Department in August 2012. So when it comes to the impact of public health spending, he’s seen both sides of the coin.

“Coming from (the state level), I was pleasantly shocked and surprised with the support we have for public health in this community because, overall, from a statewide standpoint, that is not the case, and that is not what I was used to coming from the state department,” Clardy said. “Statewide public health is tremendously underfunded. Tremendously.”

And it’s not necessarily a Midwestern problem. In fiscal year 2014-2015, Arkansas budgeted $49 per resident and ranked 13th nationally. Iowa’s budget was $38.90 per resident, ranking 22nd. Even Kansas, ranked 47th, earmarked more than twice the amount for public health spending than Missouri did: $12.40 per resident.

“It would take almost $19 million to move us from 50th to 49th. That’s how bad it is,” Clardy said. “That’s how underfunded public health is from the (state) general fund.”

It's also worth noting that the Centers for Disease Control and Prevention, a federal public health agency that allocates money for states' public health spending, doesn’t provide Missouri with much funding compared to the rest of the nation either. Missouri received only $17.33 per capita in fiscal year 2014-2015 from the CDC, ranking 44th nationally.

And it shows. According to the Trust for America’s Health, a nonprofit health policy organization, Missouri is suffering in some of the main indicators of public health. Their most recent data says 30 percent of Missouri adults are obese, 21 percent use tobacco and 32 percent have hypertension.

The CDC reports that tobacco use is the leading cause of preventable death in the U.S. 

Bert Malone, vice president of the Missouri Public Health Association and a former employee of the Kansas City Health Department, has testified several times in front of the state's Appropriations Committee, highlighting the consequences of low public health funding. Malone was frustrated that these efforts and the efforts of other organizations that advocate on behalf of local public health agencies have done little to raise Missouri from being “among the cellar-dwellers” of public health funding.

So many local health agencies throughout the state, especially those in rural areas, have had to reduce their services, staff and hours, Clardy said. The Jefferson County Health Department, located less than an hour outside of St. Louis, recently had to cut Friday from its business week due to low funding, Malone said.

'Where the rubber meets the road'

There are substantial differences in the functions of state and local health departments. The Missouri Department of Health and Senior Services does not provide any direct health services to the public. It functions as one source of funding for local public health agencies throughout the state. It also makes public health policy and helps local agencies interpret and implement them correctly.

Local agencies, on the other hand, are “where the rubber meets the road,” Clardy said.

By that he means local public health agencies, which serve individual cities and counties, have the ability to implement specific programs. For example, Boone County’s Health Department provides flu shots to residents five days a week, offers nutrition counseling for families and follows up on complaints about restaurants from the public almost immediately, among other things.

“Could we do more with more public health funding? Absolutely,” Clardy said. “But I think that with the funding that we currently have, we’re able to provide the public health services the community expects of it.”

It’s important to distinguish between medicine and public health: medicine focuses on the health of the individual, whereas public health focuses on the health of a community as a whole.

In public health, prevention is key. An analysis by the Trust for America’s Health found that investing $10 per person each year in community prevention programs that “increase physical activity, improve nutrition and prevent smoking and other tobacco use could save the country more than $16 billion annually within five years — a return of $5.60 for every $1 invested.”

But spending by public health agencies has only declined in recent years. According to the American Journal of Public Health, the combined federal, state and local public health spending has declined from $281 per person in 2008 to $255 per person in 2014, about a 9 percent decrease.

The issue of public health funding is complicated, but the results of low funding are easy to understand.

“What it all boils down to in the end is less services available to the community,” Clardy said.

Supervising editor is Katherine Reed

  • Spring 2018 advanced reporter covering the Community beat. I am a final-semester senior studying print and digital reporting. Reach me at, and follow me on Twitter @hannahcblack.

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