BACKGROUND: Recently-enacted cuts in government funding for Medicaid, public health, and social service programs threaten to increase uncompensated medical care and medical debt levels as more people lose insurance coverage, experience preventable health conditions and seek treatment in costly emergency department and hospital settings. Intentional efforts to align medical, social, and public health delivery systems can help communities share resources and mitigate these problems. We use novel data from the National Longitudinal Survey of Public Health Systems (NALSYS) to identify which communities have achieved strong alignment among these different systems, and to quantify the health end economic benefits of this alignment.
METHODS: We followed a national sample of 618 U.S. communities using NALSYS collected approximately every two years from 2014 through 2026, including 32 Colorado communities. Public health officials reported information about the implementation of 20 guideline-recommended public health practices, and the networks of organizations that collaborate to implement each practice, including medical, public health and social service organizations. We constructed network measures of systems alignment in each community, including shared financing, decision-making, and service delivery. We linked NALSYS with contemporaneous CMS data on uncompensated hospital costs and data on medical debt from consumer credit records. Generalized linear models with two-way fixed effects are estimated to assess how changes in system alignment influence uncompensated care and medical debt.
RESULTS: 28% of communities improved system alignment by at least 10 percentage-points (pp) over the 12-year period, while 37% experienced reduced alignment of at least 10 pp. Improved alignment was associated with a 5.9 pp decrease in hospital uncompensated care (p
