Legislature poised to consider massive health care funding increase

In Indiana, the price tag for the proverbial ounce of prevention might start at $242 million.

The governor, some legislators and many health experts think that’s the amount needed to start moving local health departments into a different way of doing business. Wayne County’s top health official is hopeful the upcoming General Assembly will find the money.

At 77 years, life expectancy in Indiana is consistently lower than in 39 other states—on average, nearly two years lower. In fact, Hoosiers are living as long now as in 2010, according to the Centers for Disease Control and Prevention.

A special Governor’s Public Health Commission (GPHC) concluded, after a year of study, that much more should be done to dig out of 40th place by spending more money on preventing health problems rather than simply responding to issues when they occur. In August, the Commission made 32 recommendations that will be taken up when the General Assembly convenes in January.

“These would be the biggest changes I’ve seen in my career and I’ve been in public health over 20 years,” said Christine Stinson, Wayne County Health Department executive director. “This would be a shift from reactive public health to proactive public health.”

Improving statewide public health county by county

One recommendation is to somehow increase the dollars Indiana spends on public health to the average amount spent by states nationwide. According to the GPHC report, Indiana ranked 45th nationally for state government public health spending in 2021. Pre-pandemic (2018-2019) state and CDC spending per person in Indiana was $55, versus $91 nationally.

The increase from $55 per capita to $91 would put the price tag at $242 million, most of which would go to local health departments, such as the one Stinson leads.

“That’s a huge sticker shock,” she admits, “but what we get out of it will be remarkable.”

Under the GPHC recommendations, counties that agree to provide a standard list of services would qualify for the additional funding. Counties would not have to participate, but they would not receive the funds.

Under current practice, health departments have no such standard list of services and they vary widely. Counties pay much of the cost for health departments through local property tax, and that resources varies widely depending on county size. That’s why the report calls for the state to provide funding for the additional services.

Stinson told the Wayne County Board of County Commissioners last Wednesday that this county would actually qualify for additional funding of $30 per person due to its low ranking in health indicators. Now, the department is most known for its vaccination and vital records functions, along with regulatory services such as restaurant inspections.

For the added funding, she envisions working with private health care providers, schools, other government entities, and community organizations. She sees smoking cessation programs, drug abuse education, obesity and diabetes education. She recommends “[a] lot more prevention; we could educate people about distracted driving, driving high. Free testing for lead. Testing of water wells for substances that are in groundwater but we are not testing for now.”

Public health and the state government

The Indiana State Chamber of Commerce has not taken a firm position on how much additional spending for public health it will support, one of the state chamber’s vice presidents for government affairs said. In a video session with Wayne County Area Chamber of Commerce members on Dec. 2, Mike Ripley from the state chamber said, “We don’t know if that ($242 million) is the right amount and we don’t know the outcomes. We’ll be supporting it if there are outcomes tied to it.”

Gov. Holcomb will present a budget proposal to the House of Representatives. The House will review and debate the spending priorities.

According to an Indiana Capital Chronicle news report of last week’s initial budget committee hearings, while the state has a $4 billion in reserve funding, much of that is earmarked, meaning it cannot be spent for anything new. The biggest part of state spending is for education. The article said that $243 million for public health is among the governor’s budget priorities, along with 5% average pay raises for state employees and more money for technology and transportation costs.

State Sen. Ed Charbonneau plans to write a Senate bill that would put the GPHC’s recommendations into practice. Charbonneau, who represents four mostly rural counties in northwest Indiana, chairs the Senate’s health and provider services committee and serves on its appropriations, tax and fiscal policy and rules and legislative procedure committees.

He said his bill will include outcomes. He makes a case for the cost: “When we invest $250 million in a project to move (businesses) to Indiana, you’re going to see return on investment quickly, in one or two years. When you’re talking about health care to improve the lives of people, return on investment isn’t going to show up for 15 years.”

Appointed by Gov. Eric Holcomb in August 2021 and co-chaired by former State Sen. Luke Kenley of Noblesville and former State Health Commissioner Judith A. Monroe, the GPHC included leaders in local and state government and public health. It conducted meetings statewide and online surveys to get input. Its 107-page report can be found online at www.in.gov/health/files/GPHC-Report-FINAL-2022-08-01.pdf.

Why the GPHC’s recommendations

An executive summary contained in the Governor’s Public Health Commission’s report states:

“Research shows that the biggest impacts to our health and wellbeing are outside of the physician’s office – they are our behaviors and the environments in which we live and work. The importance of healthy environments and sound health education has never been greater. These factors are the primary domains of the public health system.

“In fact, most of the life expectancy gains achieved during the 20th century – approximately 25 of 30 additional years – are attributable to public health programs and interventions focused on preventing people from getting sick or injured in the first place and on promoting wellness by encouraging healthy behaviors.

The longevity gains of the last century, however, are threatened by contemporary public health challenges and the prominence of non-communicable diseases, especially:

  • Rising deaths from drugs, alcohol, and suicide
  • Rising rates of adult and child obesity
  • Persistently high rates of adult tobacco use and teen vaping
  • Continuing risks from drug-resistant disease agents and infectious diseases such as measles, hepatitis, tuberculosis, HIV/AIDS, COVID-19, and others – each with the potential to spread rapidly across the state, across the country, and around the world.

“In fact, life expectancy in Indiana has been declining since 2010, when it peaked at 77.5 years. Indiana’s life expectancy in 2019 was 77 years, almost two years below the U.S. average of 78.8, placing us 40th in the nation. (CDC National Center for Health Statistics. (2022, February).)

“Of even greater concern is that difference between the Indiana county with the highest life expectancy and the county with the lowest life expectancy is almost nine years. This is clear evidence of the health disparities that exist across our state.”

The Commission’s recommendations

The Governor’s Public Health Commission made these recommendations for changes to Indiana’s system of public health care. The recommendations and action items to achieve them are found in the GPHC report, available online at www.in.gov/health/files/GPHC-Report-FINAL-2022-08-01.pdf.

  1. Establish baseline service standards for all local health departments, or LHDs.
  2. Expand Indiana Department of Health resources to support LHDs and interlocal collaboration.
  3. Assist LHDs to engage local businesses, health providers, schools, and other governmental and non-governmental organizations to promote public health in the community.
  4. Update Local Health Board, or LHB, appointments to reflect current public health workforce and key community representation.
  5. Ensure policy supports sharing of resources or consolidation of LHDs if desired by local partners.
  6. Promote delivery of public health services at the county level or higher, including allocation of funding.
  7. Expand personnel eligible to serve as a local health officer and require new appointees to complete public health training.
  8. Provide financial and technical assistance to LHDs pursuing accreditation or reaccreditation.
  9. Provide local health departments with stable, recurring, and flexible funding to build and sustain their foundational public health capacities.
  10. Provide LHDs with administrative support and other flexibilities to leverage all available funding sources.
  11. Establish consistency in the tracking of the public health resources and calculate the return on investment of additional funding allocations.
  12. Coordinate current initiatives and provide a framework for the development of a state health workforce plan.
  13. Ensure representation of public health on Indiana workforce initiatives.
  14. Through the Health Workforce Council, enhance workforce reporting to understand public health and clinical workforce needs and the status of the talent pipeline.
  15. Expand health workforce recruitment, training, placement, and retention into areas of need.
  16. Establish a State Public Health Data System Advisory Committee that includes local representation.
  17. Formalize and strengthen the state’s relationship with a Health Information Exchange (HIE) partner to promote improved clinical outcomes and outbreak management.
  18. Enhance data analytics tools and resources for local public health.
  19. Maintain state-led digital transformation efforts to modernize public health systems and paper-based processes.
  20. Increase utilization of IDOH’s EMResource tool across all Indiana hospitals, LHDs, first responders, healthcare facilities, and applicable government agencies.
  21. Require LHDs to participate in the CDC Public Health Emergency Preparedness (PHEP) grant program.
  22. Enhance IDOH’s emergency services and supplies capacity.
  23. Ensure local level EMS readiness through expansion and sustainability of EMS workforce.
  24. Improve regional coordination efforts to ensure a seamless emergency response.
  25. Support policies to increase the availability of school nurses.
  26. Increase access to services to support whole child wellness.
  27. Support evidence-based health education, nutrition, and physical activity in schools and early childhood education settings.
  28. Support access to health screenings and services that can be appropriately delivered in school and early childhood education settings while maintaining parental/guardian consent mechanisms.
  29. Reinforce meaningful implementation of school wellness policies.
  30. Support the development of school-based health centers.
  31. Increase provider awareness of public health initiatives, opportunities, and requirements.
  32. Address childhood injury and violence prevention.
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Bob Hansen is a reporter for the Western Wayne News.