November 6, 2022
Adopt the Governor’s Public Health Commission Report Proposals
Last summer, the Governor’s Public Health Commission delivered its final report. The Commission was established to find ways to improve Indiana’s public health system in the wake of the COVID pandemic. It was led by retired Senator Luke Kenley, one of our state’s most consistent fiscal hawks, and Judith Monroe, former state health commissioner. They were joined by experts in local public health departments, the state health department and healthcare professionals.
The 107-page report, available at www.in.gov/gphc, is unusually detailed and unlikely to be read by most Hoosiers. The Commission was charged to make recommendations for better delivery of public health services in ways that make Hoosiers healthier and give them more equitable access to care. The report also looked at the structure of local health departments.
The very first things Hoosiers should know is that we are far less healthy than we should be. Our overall health ranking sits at 40th out of 50 states. Our biggest problems are in areas that are the most susceptible to public health interventions. We do poorly in diabetes, obesity, smoking, and early death by young people. We have a terrible infant mortality rate, and, across Indiana, healthcare outcomes vary greatly by income and overall wealth in a community. In the places where a better public health system could do the most good, they are the least well supported.
Poor health among Hoosiers makes doing business in Indiana more expensive through higher health insurance costs. As I often mention in this column, poor public health is far from the only cause of our high healthcare spending in Indiana, but it is one that the legislature can readily address. This report has very detailed changes to legislation and offers 32 detailed recommendations. As I see it, these recommendations do three big things.
First, the recommendations make the role of public health departments more locally focused. Changes to local public health departments would make them more responsive to the needs of schools, first responders and other community groups. They also would task local public health offices to focus on coordinating activities like free clinics in schools or neighborhoods. Importantly, these recommendations make the relationship between counties and the state much more of a partnership than a top-down bureaucracy. The healthcare needs of each county differ, sometimes dramatically. These recommendations allow local governments to focus on their own local needs.
Second, the recommendations outline a number of steps so that the local public health departments can get better at their jobs. This includes professional standards for employees and more coordination with local health care providers, state agencies and first responders. The proposals range from allowing local health departments to bill Medicaid when they deliver clinical services to requiring a common minimum set of services that will be provided in every county.
Third, these recommendations will force local health departments to become more effective in emergency response, health education and identification of impending threats to public health. They do this by requiring data sharing, more study groups and coordination with other agencies and private providers who do this work.
In the wake of COVID, many citizens will watch changes to local health departments with some skepticism. So, it is helpful to think about what these recommendations don’t do, as well as what they do try to accomplish. Nothing in this Commission report would change rules about wearing masks or how decisions are made about a pandemic. Those are part of a different set of rules that were modified after the pandemic. This is not a big government seizure of the local health departments.
A better way to think about the Commission’s proposals is how they would affect the more mundane daily challenges to public health. I’ll offer two examples. First is the HIV/AIDS crisis in Scott County back in 2014. A local physician noted an increase in the number of patients, but delays in reporting to and by the local health department as well as delays in analyzing data meant that the response was delayed significantly. By the time the state fully recognized the problem and took action, the disease spread substantially.
One estimate in The Lancet (Gonsalves & Crawford, 2018) was that the response delays led to as many as 170 additional HIV infections. With lifetime costs of treating HIV as high as $400,000 that was easily a $65 million failure, in just one county. But, I think the second example is even more urgent and widespread. A modern, highly trained local health department would be among the first to detect an uptick in opioid overdoses or even more dangerous drugs such as fentanyl. These are a chronic problem across Indiana and much of the nation.
Local health departments like those proposed in the Commission’s recommendations would be able to better support police, EMS and hospitals. More importantly, they’d be able to share data in ways that might limit the spread of the disease. Most importantly, they’d also be able to more fully support schools and other local groups who are educating citizens about the risks of these drugs. We need these changes, now.
Today, in counties that fully fund their local health departments, many of the best practices are already in place. In other places, a small, inadequately resourced staff fails to make much of a dent in the many healthcare problems facing Hoosiers. The Commissions’ proposals would make sure all of us have access to an effective local health department services.
Naturally, adopting all these new proposals are not a panacea. It will take some time, maybe decades, to really improve our poor public health rankings. But, the gaps identified during the pandemic mark a very good time to take more seriously the challenges Indiana faces in public health. Of course, this is going to cost money and take time.
The Commission noted that raising our state funding up to the national average per citizen will cost another $242 million per year. Part of that amount will need to come from state money, and part of it will need to be local money. Everyone needs some “skin in the game” with this problem. But, here’s the thing about spending tax dollars on public health: You will either pay now, or pay later. Paying now is a lot less expensive.
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