Advocates want to restructure public health in Indiana.

Is the legislature willing to pay?

Shari Rudavsky

From Indianapolis Star

Even before the pandemic, Indiana trailed most other states in many critical public health metrics, including life expectancy, which has been decreasing steadily since 2010.

By 2019 life expectancy in Indiana was 77 years, almost two years below the national average. So Gov. Eric Holcomb convened a special commission in 2021 to look at steps Indiana could take to improve health overall.

The answer, when the commission delivered its final report in August: Restructure the state’s public health system, a proposal that came with a suggested price tag of about $242 million a year. That’s a hefty lift for a state legislature that has a history of lowering taxes while underfunding services, including public health. Currently Indiana ranks 45th in the nation for funding public health, according to America’s Health Rankings.

The chance the state meets that $242 million request already looks bleak. Even before the Indiana General Assembly has convened, Holcomb announced last Friday that at least for the first year, he would cut the request in half.

Meanwhile, legislators are making no promises about what they will or won’t fund, especially because the funding for the proposal would be ongoing, not a 1-time expenditure.

After the revenue forecast last week Sen. Ryan Mishler, R-Bremen, the Senate’s lead budget writer, said lawmakers will have to consider whether to financially back restructuring the public health system for the foreseeable future.

“(W)e’ll have to discuss that because that’s ongoing,” he said. “So we have to really take a hard look at that.”

If the legislature does give the nod to the Holcomb’s request of $120 million, he said, lawmakers may not be able to double that in 2024, as he said the budget will be tight in year two. Legislative leaders are bracing for a recession.

Still, he said, the legislature will likely allocate some money to public health.

“I think you’ll see us do something,” he said.

However, it’s not clear at this point the minimum amount of money needed to go ahead with restructuring, plan proponents say.

Advocates’ request of $240 million annually after the initial year would put Indiana at the national average for public health spending. Whittling that number down could impact the success of the restructured public health system, said Paul Halverson, a commission member and founding dean of the Fairbanks School of Public Health at IUPUI.

“If we cripple the investment from the very beginning, we’re not going to achieve the goals,” he said. “No, it’s not possible to do all that we expect with half the money long-term. … It’s clear what the potential benefits are and to go less is to really cheat the people.”

How we got here

Indiana has a long history of underfunding public health dating back to the middle of last century. Since that time, public health largely has been the responsibility of local health departments funded by county governments. The state’s 92 counties have had to juggle public health spending against roads, jails, courts, a particular challenge for those with populations under 50,000.

State lawmakers have been happy to keep public health spending the purview of local government, paying little attention to the dismal health statistics that Indiana posted year over year. Often they heard about Indiana’s high smoking rates in debates over whether to increase the state’s cigarette tax; despite such discussions Indiana’s cigarette tax remains the 39th lowest in the country.

Former sate Sen. Luke Kenley knew about the high smoking rates and low taxes but until Holcomb asked him to co-lead the public health commission, he said, he did not comprehend just how short the state falls when it comes to public health. Kenley had been the Senate’s lead budget writer before retiring in 2017.

Other states have a range of approaches such as having the state health department run all local offices but the commission settled on the idea of having the state health department work with local departments.

Restructuring public health in Indiana

Under the concept, the state will funnel money to the local health departments with an 80-20 match. Local governments would have the option to not participate.

“We think it needs to be a partnership between local government and state government,” Kenley said. “We’re not forcing it down their throat but it’s going to be so attractive and the benefits are going to be so good, we’re pretty sure that over time, just about everybody will sign up.”

Local health departments that accept the new funds will have to provide core public health services determined by state health department staff, said Dr. Kristina Box, Indiana State Health Commissioner and a member of the governor’s commission. The state health department will develop regional/district health offices to support the 94 local health departments — each county plus Gary and Fishers — more in the field.

Some of the smaller health departments may wind up sharing services, Box said. For instance, a county of 16,000 people would not necessarily need a full-time food service or immunizations coordinator but three neighboring counties could share such an employee.

Keeping health department administration local, however, remains critical, she added. During the pandemic, people in many communities made it clear that they trusted their local health authorities and doctors more than they did people they did not know, Box said. In addition, local elected officials made it clear they wanted to have latitude to make their own calls when it comes to public health.

“Local government wants to kind of run the show,” Box said. “They know their communities and their counties the best and they want to make the decisions, which we really are supportive of.”

Public health spending pays off, proponents say

To figure out the funding level, the commission looked at how much Indiana spent pre-pandemic on public health —$55 year per person, significantly less than the national average of $91 per person a year. The commission suggested taking the difference of $36 and multiplying it by the state’s population of 6.8 million.

Although the initial plan was to ask for about $242 million a year, Kenley says he can see the wisdom of starting off with that half amount in the first transitional year as the new system ramps up.

Cutting future funding, however, would likely scuttle the plans to restructure, especially because the initial request was based on pre-pandemic spending.

“It would be disappointing for us to fall back because of the purchasing power of the dollar is getting less and less, we would be even further behind (other states),” he said.

Describing himself as not much of a spender, Kenley said that he recognizes that advocates of the plan will have to work hard to persuade legislators and their constituents to spend the money to help Indiana.

Evidence shows that for every dollar invested in public health, communities see a $7 to $14 return on investment, Box said.

Consider smoking: When a person quits, studies suggest, they immediately decrease their risk of developing bronchitis, pneumonia or having to miss work. Yet only just over a third, or 38, of Indiana counties have tobacco prevention and treatment programs.

When Box thinks about previous public health successes in the state, she cites the example of the Scott County HIV outbreak connected to intravenous drug use. In the wake of the outbreak, public health workers connected people affected to health care to treat their drug- and HIV-related conditions and established a syringe program, the first such program in Indiana.

But in what some might see as a sign of Indiana’s lack of appetite and perhaps an omen for this plan, county commissioners scrapped the program in 2021.

A 25-year veteran of the state legislature, Kenley recognizes that there are no guarantees the commission’s proposal will be met with approval. If the request doesn’t pass this year, he said, public health advocates will continue working on it.

“If you’re doing the right thing, you’re working on the right issue, and the facts are with you,” he said. “You just keep working because eventually you win these things.”

IndyStar reporter Arika Herron contributed to this report.

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