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OPINION

Two red states show how the nation’s public health system can be fixed

Reforms in Kentucky and Indiana suggest a path forward.

A list of the confirmed COVID-19 cases in Salt Lake County on May 13, 2020, early in the COVID-19 pandemic, at the Salt Lake County Health Department, in Salt Lake City.Rick Bowmer/Associated Press

The coronavirus pandemic exposed the shortcomings of the US public health system. There is a decentralized set of 2,800 public health agencies that are understaffed, undervalued, and uncertain about their mission. But two Republican-led states are demonstrating how bipartisan reform can lead to a better and more fiscally stable public health system.

In July 2022, Kentucky implemented its Public Health Transformation program, a bipartisan initiative that will dramatically increase state funding for local efforts to deliver core public health functions. In Indiana, a bipartisan Public Health Commission recently released a blueprint for reform that will bring dramatic improvements in how public health works in the Hoosier state.

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What explains these initiatives in an increasingly partisan political environment? And what lessons do they hold for federal policy makers? We visited these states to find out.

Kentucky has 61 local health departments, most of which until the last decade generated sizable Medicaid revenue by providing medical services to low-income residents. This revenue subsidized the agencies’ more traditional activities such as providing birth certificates, conducting restaurant inspections, investigating disease outbreaks, and participating in emergency response activities.

Recently, however, local health departments in Kentucky, like their counterparts around the country, have reduced their role as providers of care, prompted by concern that these activities dilute their “population” health mission, especially since others (i.e., community health centers) presumably fill the safety net role. This shift aggravated an already difficult financial situation. State and federal funding had declined precipitously following the 2008-09 recession. Pension costs for health department staff were rising. Local elected officials were reluctant to raise taxes.

In 2020, Kentucky policy makers changed course, enacting the Public Health Transformation initiative, under which the state provides funding (effective July 2022) to ensure that local departments deliver the “core” public health services to every resident. In return, each county provides at least 1.8 percent of its property tax revenue to its health department to help fund such services and it conducts an assessment to evaluate (and address) other community-based needs.

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Why this bipartisan legislation in a red state? Democrats saw an opportunity to increase funding for public health while Republicans saw an opportunity to send needed funds (and policy making discretion) to local communities. Indeed, the state’s association of local health departments developed the legislation, found legislative champions on both sides of the aisle, and worked with a supportive governor and health commissioner.

Indiana followed a different path toward a similar outcome. The state’s 94 local health departments are underfunded and understaffed largely because they rely on local property taxes for over 75 percent of their budgets. After the pandemic exposed the gaps in that system, Republican Governor Eric Holcomb created a public health commission to investigate how the state could do better. To navigate the tricky politics of convincing the conservative General Assembly to increase public health funding, the governor persuaded a recently retired and widely respected conservative Republican legislator, Luke Kenley, to co-chair the commission. The commission’s final report proposes significant increases in state funding for local officials to deliver the “core” set of public health services. While the reform process in Indiana is still underway, the tea leaves point toward a sizable expansion of state support for local health departments.

To be sure, the federal government has also taken steps to rebuild the public health workforce. The American Rescue Plan appropriated $7.66 billion to fund public health jobs. The Centers for Disease Control and Prevention has already sent $2.2 billion of these funds to state and local health departments, money that must be spent by July 2023. Another $3 billion is to follow this fall.

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But implementation of the ARP program has proceeded more slowly than expected. Kentucky received $27 million in the first round of ARP workforce funding, but 12 months later had spent less than $1 million. Indiana got $40.3 million, but it too had a slow start creating new jobs and spending the money.

Why the delays? Some local elected officials are hesitant to create new positions that are funded for only two years. Other obstacles include complicated rules on creating and posting new jobs, low pay, poor morale, and inadequate administrative capacity. Indeed, most local public health officials we met were either unaware of the ARP funding or frustrated by the limited impact. In Kentucky and Indiana, the local public health community was more engaged in the state reforms than in trying rapidly to spend the one-time federal dollars.

What then are our takeaways?

First, local governments cannot afford the fiscal burden imposed by the decentralized public health system. Federal and state governments must contribute more. Second, there are political paths to increased state funding but they require mobilizing commitment across partisan lines, winning the support of governors, and patient efforts to explain why new terms of trade between the state and its localities make sense. Third, federal officials should learn from these state laboratories. Congress should provide sufficient funding to support the core public health tasks delivered by local public health departments, supplementing these funds as necessary during a crisis (such as a pandemic). This core funding should not be disease specific, and it should not be time limited. Fourth, local communities should then assess their needs to determine which public health services beyond the core should be funded by local dollars. Finally, even with increased funding, the public health workforce crisis will continue until we make public health a more attractive career path with fewer bureaucratic barriers to entry.

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The US public health system has neither the resources nor the capacity to protect, preserve, and promote the health of the population. The ARP infusions, though welcome, are not by themselves sufficient to rescue that system. That goal will require adroit policy innovation by, and careful coordination among, the federal, state, and local levels of the US federal system. Kentucky and Indiana, two Republican-dominated states, may provide a blueprint for how to build a bipartisan coalition for public health reform. Congress and the CDC should take note.

Michael S. Sparer is chair of the Department of Health Policy and Management at the Mailman School of Public Health at Columbia University. Lawrence D. Brown is professor of health policy and management at the Mailman School.