Associations between previous local health expenditures and COVID-19 mortality outcomes large cities in the United States: Results from a forward-selecting linear regression analysis

Background: Decision-making before the COVID-19 pandemic—including the budgeting and expending of public health financing—may have impacted the ability of health systems to mitigate the health consequences of the outbreak. Theoretically, greater investments in public health preceding an outbreak ought to improve health outcomes during an emergency response. Following this reasoning, this research investigates the relationship between local public health expenditures and pandemic-related mortality in the 50 most populous cities in the United States in 2020. Methods: Forward-selecting linear regression models were used to examine this relationship. Dependent variables included local-level measures of the excess mortality and COVID-19 mortality rates; the primary independent variable was the five-year average of local public health expenditures per capita (2015–2019). Data on other demographic, socioeconomic, and pandemic response considerations that may have modified or confounded this relationship were included in regression models. Results: Multiple linear regression models suggested that previous local government public health expenditures were not meaningfully associated with improved pandemic mortality outcomes as measured by excess mortality or reported COVID-19 mortality. Instead, results suggest that education and temporal considerations were the factors that were significantly associated with mortality levels during the first year of the pandemic in large cities in the United States. Conclusions : Acknowledging broader public health financing trends that are characterized by decreasing and unpredictable funding streams, these results suggest that addressing public health emergencies at the scale of the COVID-19 pandemic in the United States will likely require more substantial and sustained investments in public health, nuanced and data-informed approaches for allocating financing, structural changes to the public health system that address social-determinants of health, or a combination of these approaches. Trial Registration: Not applicable.