Last summer, the Governor’s Public Health Commission released 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 tax hawks, and Judith Monroe, former state health commissioner. They were joined by experts from local public health departments, the state health department and medical professionals.
The 107-page report, available at www.in.gov/gphc, is exceptionally detailed and unlikely to be read by most Hoosiers. The Commission was charged with making recommendations for better delivery of public health services so as to improve the health of Hoosiers and give them more equitable access to care. The report also examined the structure of local health services.
The very first thing the Hoosiers need to know is that we are in much worse health than we should be. Our overall health ranking is 40th out of 50 states. Our biggest problems are in the areas most susceptible to public health interventions. We have poor records on 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 a community’s income and overall wealth. Where a better public health system could do the most good, they are the least well supported.
The poor health of the Hoosiers 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 healthcare costs in Indiana, but it is one that lawmakers can easily address. This report presents very detailed changes to the legislation and offers 32 detailed recommendations. In my view, these recommendations do three main things.
First, the recommendations make the role of public health services more local. Changes to local public health departments would make them more responsive to the needs of schools, first responders and other community groups. They would also direct local public health offices 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 differ, sometimes significantly. These recommendations allow local governments to focus on their own local needs.
Second, the recommendations outline a number of steps for local public health departments to improve in their work. This includes professional standards for employees and greater coordination with local health care providers, state agencies and first responders. The proposals range from allowing local health departments to charge for Medicaid when they provide clinical services to requiring a common minimum set of services to be provided in each county.
Third, these recommendations will compel local health departments to become more effective in emergency response, health education, and identification of imminent public health threats. To do this, they require 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 services with some skepticism. So it’s worth thinking about what these recommendations don’t do, as well as what they attempt to accomplish. Nothing in this Commission report would change the rules around mask-wearing or how decisions are made in the event of a pandemic. These are part of a different set of rules that were changed after the pandemic. It’s not a big government grab on local health services.
A better way to think about the Commission’s proposals is how they would affect the more mundane everyday challenges of public health. I will offer two examples. The first is the HIV/AIDS crisis in Scott County in 2014. A local doctor noted an increase in the number of patients, but delays in notifying the local health department and by delays in analyzing data delayed the response. significantly. By the time the state fully recognized the problem and took action, the disease had spread significantly.
An estimate in The Lancet (Gonsalves & Crawford, 2018) was that response delays resulted in up to 170 additional HIV infections. With lifetime HIV treatment costs as high as $400,000, this easily amounted to 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 increase in overdoses of opioids or even more dangerous drugs like fentanyl. This is a chronic problem in Indiana and much of the country.
Local health services like those proposed in the Commission’s recommendations would be able to better support police, EMS and hospitals. More importantly, they could share data in ways that limit the spread of the disease. More importantly, they would 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. In other places, a small, under-resourced staff fails to address the many health issues facing Hoosiers. The Commission’s proposals would ensure that we all have access to effective local health services.
Of course, the adoption of all these new proposals is not a panacea. It will take time, perhaps decades, to really improve our poor public health rankings. But, the gaps identified during the pandemic mark a very good time to take the public health challenges facing Indiana more seriously. Of course, this will cost money and take time.
The Commission noted that increasing our public funding to the national average per citizen will cost an additional $242 million per year. Part of this amount will have to come from state money, and another part will have to come from local money. Everyone needs a little “skin in the game” with this problem. But, here’s the thing about spending taxpayer dollars on public health: either you pay now or you pay later. Paying now is much cheaper.
Michael J. Hicks is 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 feedback to [email protected]