Abstract
Addressing the financing challenges of the governmental public health system requires a more detailed understanding of the specific role and functions of local health departments, particularly for metropolitan health departments. Many current studies and reports mistakenly aggregate all 3,000 local health departments as a single unit of analysis and, as a result, fail to highlight the increasingly important role of metropolitan health departments. These large departments represent less than 10% of local health departments, but at the same time, serve more than 60% of the US population. The largest 25 metropolitan health departments serve jurisdictions averaging 2 million persons; a larger population than 14 of the states. This article presents a description of the capacity and organizational characteristics of metropolitan health departments, the essential role these agencies play in the preparedness and health disparities areas, and the very different public health financing issues that are raised when the policy focus is on the form of local public health practice serving most of the population.