Last summer, the governor’s commission on public health submitted its final report. The commission was created to find ways to improve Indiana’s public health system in the wake of the COVID pandemic. It was led by retired Sen. Luke Kenley, one of our state’s most consistent fiscal hawks, and Judith Monroe, former state health commissioner. They were joined by experts from local public health departments, the state health department and health 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 with making recommendations to better deliver public health services in ways that make Hoosiers healthier and give them more equitable access to care. The report also examines the structure of local health departments.
The first thing Hoosiers need to know is that we are far less healthy than we need to be. Our overall health ranking is 40th out of 50 countries. Our biggest problems are in areas most amenable to public health interventions. We are doing badly with diabetes, obesity, smoking and early death among young people. We have a terrible infant mortality rate, and across Indiana, health care outcomes vary widely based on income and overall community wealth. In places where a better public health system could do the most, they are least supported.
Hoosiers’ poor health makes doing business in Indiana more expensive due to higher health insurance costs. As I often mention in this column, poor public health is far from the only cause of our high health care costs in Indiana, but the Legislature can easily address it. This report contains very detailed changes to the legislation and offers 32 detailed recommendations. In my view, 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 will also put the burden on local public health services to focus on coordinating activities such as free clinics in schools or neighborhoods. Importantly, these recommendations make the county-state relationship much more of a partnership than a top-down bureaucracy. Each county’s health care needs vary, sometimes dramatically. These recommendations allow local authorities to focus on their own local needs.
Second, the recommendations outline a number of steps so that local public health departments can improve their work. This includes professional standards for employees and more coordination with local health care providers, government agencies and first responders. The proposals range from allowing local health departments to bill Medicaid when they provide clinical services to requiring a common minimum set of services to be provided in each county.
Third, these recommendations will force local health departments to become more effective in emergency response, health education, and identification of impending public health threats. They do this by requiring data sharing, more study groups, and coordination with other agencies and private providers that do this work.
As a result of COVID, many citizens will view changes in local health departments with some skepticism. So it’s useful to think about what these recommendations don’t do as well as what they try to achieve. Nothing in this Commission report will change the rules on wearing masks or how pandemic decisions are made. They are part of a different set of rules that were changed after the pandemic. This is not a major government seizure of local health departments.
A better way to think about the Commission’s proposals is how they would affect more ordinary everyday public health challenges. I will give two examples. The first was the HIV/AIDS crisis in Scott County in 2014. A local doctor noted an increase in the number of patients, but delays in reporting to and from the local health department and delays in analyzing the data meant that the response was delayed significantly. By the time the state became fully aware of the problem and took action, the disease had spread significantly.
One estimate in The Lancet (Gonsalves & Crawford, 2018) is that the delay in response resulted in 170 additional HIV infections. With lifetime costs of HIV treatment up to $400,000, it was easily a $65 million windfall in just one county. But I think the second example is even more relevant and widespread. A modern, highly trained local health department will be among the first to detect an increase in opiate overdoses or even more dangerous drugs like fentanyl. These are a chronic problem in Indiana and much of the nation.
Local health departments such as those proposed in the Commission’s recommendations will be better able to support the police, emergency services and hospitals. More importantly, they will be able to share data in ways that can limit the spread of disease. Most importantly, they will also be able to more fully support schools and other local groups that educate 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. Elsewhere, a small, underfunded staff fails to do much of the many health problems facing Hoosiers. The Commission’s proposals will ensure that we all have access to effective local health department services.
Naturally, accepting all these new proposals is not a panacea. It will take some time, perhaps decades, to improve our truly poor public health ranking. But the gaps uncovered during the pandemic mark a very good time to take more seriously the challenges facing Indiana in public health. Of course, this will cost money and take time.
The committee noted that raising our state funding to the national average per citizen would cost an additional $242 million per year. Some of that amount will have to come from state money, and some of it will have to be local money. Everyone needs “skin in the game” with this issue. But here’s the thing about spending tax dollars on public health: You either pay now or you pay later. Paying is now much cheaper.
Michael J. Hicks is the director of the Center for Business and Economic Research and the George and Frances Ball Distinguished Professor of Economics at Ball State University’s Miller College of Business. Send comments to [email protected]