Public Health Needs a Political Strategy, Not Just Funding
Researchers from Columbia University visited five states to see how they were using money from the American Rescue Plan to build their public health workforces. They found that politics might matter even more than dollars.
America’s public health workforce was shrinking for years before COVID-19. Workers who stood fast when it hit took on the challenge of containing a deadly, rapidly spreading disease that had never been seen before while scientists were still working to understand it.
After an initial flourish of public gratitude early in the pandemic, expressions of thanks were overtaken by a wave of hostility and second-guessing by public officials and conspiracy theorists. For many workers nearing retirement, or those new to their jobs, it proved to be too much.
The American Rescue Plan (ARP) included $7.7 billion for the creation of 100,000 new public health jobs. State, local, tribal and territorial health agencies received about $2 billion of this to be used between July 2021 and this month, June 2023.
Columbia University researchers obtained support from the Commonwealth Fund to find out how states were using these ARP dollars. They interviewed leaders from the Centers for Disease Control and Prevention (CDC) and workforce experts, then traveled to five states to discover whether federal support, in combination with state efforts, was resulting in progress.
Their findings were published in the Milbank Quarterly in May, in a paper that provides a rare and detailed look at the inner workings of these public health systems.
Bottom line: they learned real-world change depends on more than funding. America’s public health system is complex and fragmented, with nearly 3,000 local health departments at its core. Dollars might be the lifeblood the system needs, but it takes political capital and bipartisan cooperation to put them to work.
“The politics of public health requires a closer look at the role played by county commissioners, mayors and other local elected officials,” they concluded. “We need a political strategy to persuade these officials that their constituents will benefit from a better public health system.”
Michael Sparer, a lawyer and political scientist, was co-investigator for the study along with his colleague Lawrence Brown. Sparer has worked at Columbia University’s school of public health for almost 30 years and serves as chair of its Department of Health Policy and Management.
Sparer says the new research goes beyond the many reports about the need to rebuild the public health workforce by examining the current situation from the ground up. The states that he visited — Kentucky, Indiana, Mississippi, New York and Washington — were chosen because of their varied political climates, public health organizational structures and funding practices.
Indiana, for example, has a decentralized public health system with 94 local health departments (LHDs). The 86 LHDs in Mississippi are staffed by state workers. Just this one state-level factor impacts decisions about the use of federal and state funds.
The Kentucky Health Departments Association (KHDA) represents the interests of the state’s 61 LHDs. It has used political strategies to build bipartisan support for increased public health funding, including the Public Health Transformation Act requiring the state to provide sufficient funds for local districts to provide core services.
KHDA had a place on a committee that set priorities for ARP funding. The state has spent or obligated almost 80 percent of its initial $27 million and requested a one-year extension on the balance.
The money will fund programs including bonus pay based on hours worked during the pandemic, professional development and tuition assistance, regional epidemiologists and “experiential learning days” at health departments. Kentucky was the only state of the five where the researchers observed a “truly collaborative process between LHD officials and the state health department.”
This wasn’t the only cooperative effort Spacer encountered. In 2021, Indiana Gov. Eric Holcomb created a commission to develop bipartisan strategies for strengthening the state’s public health system. He recruited a popular former health commissioner and a respected Republican legislator as co-chairs, and the commission put forward recommendations for legislation action.
The commission dealt with pushback from LHDs in this home-rule state by meeting with county commissioners and local leaders. A letter of support sent to the Indiana Business Journal by groups representing mayors, county commissioners and county councils proved to be pivotal in gaining legislative support for increasing public health funding, Sparer says.
LHDs in Indiana didn’t have a voice in ARP fund allocation, however. While appropriation decisions by the state’s department of health meet ARP guidelines, they don’t include money for workforce development.
Failure to Communicate
In ways that vary from state to state, the dispersed nature of public health authority can prevent agile response to funding opportunities from the federal government. Sparer, who has studied Medicaid for decades, notes that it gradually transitioned toward more national control.
“We need national oversight of the public health system, but that has to work well and effectively with a decentralized public health system,” he says. “That is what we have, and it is not going to disappear anytime soon.”
That doesn’t have to be the only way forward. For the most part, public health officials don’t talk to state legislators, county executives, city councilmembers or mayors, Sparer says.
These are the people who make bureaucratic rules and approve funds and new positions, essential allies in lobbying for legislative changes. Bad or neglected relationships with them are a “pre-existing condition” that can affect public health systems.
Mark Miller, vice president of communications for the de Beaumont Foundation, once managed a team of White House policy writers. He leads the foundation’s efforts to develop effective public health messaging using insights from research projects and focus groups.
You Lost Me at “Equity”
Contentious phrases and buzzwords that don’t travel well across party lines can stop relationship building in its tracks, he says. “Do you really need to use words like ‘systemic racism’ if you want to find common ground?”
“Equity” is a key concept in public- and private-sector programs that are currently under attack. Deservedly or not, “underserved communities” or “vulnerable populations” could raise hackles in contexts where “we want everyone to be healthy” would not.
Public health aims to build support on the basis of science, but confidence that scientists act in the public interest has declined in recent years. Scientists can be resistant to “dumbing down” their messaging for non-experts, Miller says, and this works against bridge building.
“Do you want to be thorough and comprehensive, or do you want people to understand and take action on what you are saying?,” he asks.
Recommendations on language and framing for public health from the Berkeley Media Studies Group echo the importance of plain and descriptive language. They also emphasize that “message is never first,” that messaging needs to be rooted in local context and strategy.
Fostering local support is where strategy should begin, says Sparer. “You are not going to get the increased funding that you need at the federal or state level unless you have buy-in from locals — and that creates the political puzzle.”
Politics differ state to state and even between regions within states, but county executives, commissioners and administrators have an outsized role in local ecosystems, Sparer says. “What we want to do in our next study is focus on that explicitly.”