Workforce Policy Spotlight: Successfully Raising FTE Caps in Rhode Island

July 24, 2023 | Liljana Baddour, Maggie Davis

Health departments rely on their workforce to protect the public’s health and well-being strategically and meaningfully. The health department workforce is often comprised of various employment types including public health professionals directly employed as state employees, contractors, job appointments, and temporary positions.

In the decade prior to COVID-19, state and local public health agencies across the country collectively lost more than 30,000 Full Time Equivalents (FTE) as population increased and resources for public health decreased, critically hindering their ability to provide public health services and retain employees. In fact, chronic underfunding of governmental public health has led to a 15% decrease in the workforce since the 2008 recession and as the population has increased. This trend is only expected to continue, especially as public health faces ongoing workforce retention challenges and turbulent turnover stemming from moral injury and burnout exacerbated by the COVID-19 response.

In October 2021, the Public Health National Center for Innovations and the de Beaumont Foundation issued an informed estimate of staffing needed to perform basic public health services on a national scale. The analysis concluded that more than 80,000 additional staff are needed in state and local health departments to implement such services—representing an increase of more than 80%. The analysis concluded that of these additional staff, about two-thirds should be deployed to local health departments, while the remaining one-third should be deployed to state health departments.

Contract Employees Are Valuable but Can Be Costly

It is not uncommon for public health agencies to have too few positions to be able to hire direct employees to fulfil their missions. State legislatures typically control the number of FTE positions state agencies are allowed to employ. Public health departments resort to cobbling together different staffing mechanisms such as contracting with various entities including public health institutes, universities, and area health education centers to hire contractors. This mechanism allows agencies to hire contractors and typically place them 100% in public health agencies. Other staffing augmentation mechanisms include unclassified job appointments, and various forms of temporary employment.

While contract employees can fill critical gaps in health agency staffing, these employees can cost more because of staffing agency overhead and indirect rates. They can also complicate access to systems, data, onboarding, requirements, and development opportunities. Other staffing augmentation mechanisms include unclassified job appointments, and various forms of temporary employment.

During the pandemic, many health departments had a taste of what an expanded workforce could accomplish. Aided by a sudden surge of federal funding to combat COVID-19, health departments were able to open the doors to a reinforced, albeit temporary, workforce.

How Rhode Island Raised their FTE Cap

As the pandemic response ramped up, the Rhode Island Department of Health (RIDOH) infused several temporary positions into its public health workforce. However, as the once-expansive pool of COVID-era public health funding steadily—and in some cases, suddenly—evaporated, health agencies turned to addressing the root cause to meet this need. In Rhode Island’s case, this meant doing something that’s rarely done in public health: making the case to the legislature for adding new, permanent positions to their workforce.

On March 6, 2023, ASTHO virtually convened a group of public health agency legislative liaisons, workforce and HR directors, and Chief Financial Officers, to understand how RIDOH was able to increase the number of positions allowable to meet critical public health needs. The call was headed by Sandra Powell, deputy director of RIDOH, who was instrumental leading the charge on the ground in Rhode Island.

Powell shared that as RIDOH set out to raise its workforce position cap, the agency identified two major paths forward: (1) formally increasing the number of positions through the House and Senate, or (2) creating positions through the state budget process. Since the discussion aligned with the onset of the annual budget submission process, RIDOH opted for the latter.

The annual budget includes decision packages that provide justification and personnel supplements for needed positions. To help make the case for consideration in the budget, RIDOH met with the state Office of Management and Budget (OMB) to share information and provide data on the positions, turnover rates, and any other information that OMB believed would demonstrate value.

The process wasn’t easy. Powell and her team engaged community partners every step of the way and partnered alongside legislators to navigate complicated funding dynamics. They grappled with how to get approval without being able to demonstrate permanent funding, the emergence of political sensitivities when leveraging certain federal grants, and the debate over whether to hire contractors instead.

When all was said and done, the budget included 28 new permanent positions for RIDOH: eight were sponsored by the Bipartisan Infrastructure Law grant for FY23; an additional 20 were approved for FY24. Together, these positions would help cover several core public health areas, including immunization, overdose prevention, and epidemiology.

A Potential Blueprint

Rhode Island’s success represents a beacon of possibility for other jurisdictions looking to expand their workforce. While every jurisdiction comes with its own unique tangle of funding protocols, partisan tendencies, and hiring restrictions, RIDOH points to a few core principles that led to success:

• Document everything. Throughout RIDOH’s application process, the department focused on achieving airtight documentation at every turn. From hiring practices to retention rates to race and ethnicity data, every piece of information was an essential building block in making the case for more directly employed positions. The value of this painstaking documentation is two-fold: it proves an apparent need, while also demonstrating that the department has given their workforce capacity status serious thought and hasn’t simply plucked items from a wish list.
• Stay close to the cap. When petitioning for new positions, agencies might find it valuable to stay as close to the existing cap as possible to demonstrate that each position serves a vital role in the agency’s work—and that more are needed. This can be a difficult equilibrium to strike because, as is the case in Rhode Island, it takes an average of 16 weeks to fill a vacancy, meaning that the team had to work diligently to anticipate and fill holes as they emerged.
• Go above and beyond public health. When promoting the value of new positions to fill critical gaps, present public health as a force multiplier that translates into success across multiple fields and industries. For Powell, this meant being able to answer a fundamental question: why it matters for our constituency. It was important for the team to be able to translate the importance of public health to other groups less familiar with their work, and to understand that investing in positions is good for the entire community.
• Prioritize engagement. Powell continued to drive home that engaging with everyone was key saying, in part, “We worked closely with the policy liaison staff, the governor’s office, and OMB to gain advocates and ensure support for this project.”
• Persistence prevails. Above all else, Powell emphasized the value of persistence, saying that it will take multiple meetings and outreach. “There is a process and procedure to work through and it’s important to keep moving through it and working with the interested parties and advocates,” she said.

RIDOH’s position cap currently hovers at around 535 state-employed positions. While 28 might feel like a drop in the bucket compared to the estimated 80,000-person deficit, the department is eager to carry their momentum into the future and to show that making up ground isn’t impossible. It just takes strategy and persistence.

Special thanks to Sandra Powell for leading the effort in Rhode Island and sharing the story with ASTHO for the benefit of State and Territorial Health Officials.