Over the last few years, Massachusetts’ uniquely fragmented public health system has made progress in becoming slightly less fragmented. State grants and federal funding in the wake of the COVID-19 pandemic have helped communities hire staff, share services, and become better trained. But there is more work to be done to modernize a system that is often incapable of meeting basic responsibilities, like inspecting restaurants and septic systems.
A bill pending in the Legislature would create minimum standards for local public health departments while providing the money departments need to meet those standards. Transforming a haphazard, locally driven public health system into one that is regionalized and modern will be a monumental task. But it is necessary to ensure every resident has access to a comparable level of public health services — things like safe food and safe water — regardless of where they live.
Today, some communities host vaccine clinics and have a nurse available to visit elderly residents. Others have none of that. “It truly does depend on where you live as to what services you are able to avail yourself of,” said Cheryl Sbarra, executive director of the Massachusetts Association of Health Boards.
While most states operate public health services at the county or district level, Massachusetts, with its strong tradition of local control, has left public health up to individual cities and towns, resulting in redundancies, underfunding, and an uneven patchwork of services. Without even standard credentials for public health workers, a 2019 report by a Special Commission on Local and Regional Public Health stated, “Where you live determines not only the depth and breadth of public health protections that are available, but also the qualifications of the individuals providing the services.”
The COVID-19 pandemic drew attention to the system’s inadequacy when the state paid millions of dollars for contact tracing and vaccine clinics, which could potentially have been done by municipal public health officials, had those departments been better resourced and available statewide.
The special commission’s 116-page report lays out a blueprint for reform. Its recommendations include establishing statewide standards for what services public health departments should provide; sharing services across jurisdictions; improving data reporting; establishing standards for public health worker credentials; and distributing funding to help departments meet the new standards.
The Legislature began this work in 2020 by creating a grant program that funds public health staffing and training, including efforts to share services. The Department of Public Health has incentivized communities to work together by offering technical assistance.
Public Health Commissioner Robert Goldstein said from fiscal 2021 to 2023, the state provided $27 million in grants, and over 310 municipalities entered shared service agreements.
Shin-Yi Lao, director of Newton’s public health services, said Newton, Brookline, Belmont, and Arlington are sharing an epidemiologist who analyzes public health data and environmental health specialists who conduct inspections. They are considering collaborating on regional vaccine clinics and reciprocal permitting, so a camp or food truck inspected in one community can operate elsewhere.
The needs for regionalization are often greater in rural communities, which often do not have a strong property tax base to fund public health. At one point, the Franklin Regional Council of Governments was employing one full-time and one part-time staffer to cover the public health needs of 15 Franklin County towns. Grant money has since allowed it to hire more staff. “There was no possibility we could give vaccines, investigate every restaurant, every housing complaint, review every septic plan,” said Phoebe Walker, director of community health for the Franklin Regional Council of Governments.
In December 2021, the Legislature allocated $200 million in American Rescue Plan Act funds to public health infrastructure. Goldstein said the state is spending that money on training, capacity building, and developing performance standards.
The next step is for lawmakers to pass what advocates call the State Action for Public Health Excellence Act, or SAPHE 2.0. The Legislature passed the bill unanimously in July 2022, but then-governor Charlie Baker returned it with an amendment and the bill died. It was reintroduced this session.
The bill would set up a process to implement the 2019 blueprint. This includes developing statewide standards for services provided and workforce credentialing, requiring data reporting, and providing technical support and money through grants and formula-based funding. Money would be contingent on communities moving toward meeting the standards. The bill would support efforts to share services, recognizing that smaller communities would be unlikely to meet the standards by themselves.
Setting minimum standards for workforce credentialing makes sense. The state sets minimum qualifications for building commissioners and library directors. There is a need to ensure that someone inspecting pools, housing, or restaurants is qualified. Goldstein said in some places today, “We’re using a 20th-century public health workforce to operate in the 21st century.”
Data reporting is also vital. As the 2019 report notes, data are a fundamental part of public health, yet Massachusetts cannot answer basic questions like how many foodborne illnesses were traced to restaurants and were those restaurants appropriately inspected?
The Healey administration supports the bill. Goldstein said DPH can write performance standards but only the Legislature can mandate that communities follow them and appropriate money. He called the bill “an important next step for local public health.”
A preliminary cost estimate based on the 2019 blueprint, cited in testimony by the Massachusetts Municipal Association, pegs the cost at $140 million. But that number is outdated and does not consider the COVID relief spending.
The policy would unquestionably require an influx of state money. Lawmakers will have to carefully craft it to avoid placing unfunded mandates on communities and to ensure that more money gets spent on public health, rather than simply having state money supplant local money. But many states, unlike Massachusetts, do pay for public health services. And in the long term, a move toward sharing services will be more efficient than having 351 health departments.
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