Financing the Future of Public Health

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: the case for reliable and consistent funding for public health programs.

DR. STEVEN STACK:
It's tough because the people that we serve in our clinic settings and other areas are some of the most vulnerable in society and they're not often set up well to advocate, to persuade others to support this more.

So, it is difficult. It feels like a bit of an uphill battle. But I think COVID has made very clear that there's a crying need to give more attention to public health.

JANET HAMILTON:
We really need approaches for public health that are sustained—sustained at a much higher level and over the long term—because health is a long-term commitment, and investment in that for the entire population takes time.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, how dollars make the difference in public health and the need to support a new approach to funding for positions, programs, and equipment to keep communities healthy. Our guests have worked through many up and down funding cycles, and they tell us why that needs to change.

Janet Hamilton is the executive director of the Council of State and Territorial Epidemiologists. We'll find out what she's telling her members as they decide how to build on investments received as part of the COVID-19 response.

But first, we hear from Dr. Steven Stack, commissioner of the Kentucky Department for Public Health, about rebuilding an underfunded system.

STACK:
Public health is sadly chronically underfunded, and it has only become more underfunded in the decade leading up to the COVID pandemic.

So, when I became health commissioner, there was already an effort underway across the public health community in Kentucky to transform public health because we estimated that about one third of all of our health departments would be bankrupt within 12 months and that another 18% would be bankrupt within 13–24 months. So, we had over a half of the 61 health departments in the Commonwealth of Kentucky on the brink of financial insolvency within two years of me becoming health commissioner.

So, a lot of work was underway to try to address that. And then, COVID hit and interrupted some of the work on that important area and forced us to focus our attention on the pandemic while now, at the same time, giving us this opportunity to potentially escalate that work. So, you know, we've got a long way to go.

But when I look at the history preceding my time as health commissioner, what I see is, over about 10–15 years prior to last year, health departments cutting their full-time equivalents by up to as much as half over that 10–15 years, which is a sign of some of the substantial reductions in funding they were facing.

JOHNSON:
Just not a priority for people writing the checks?

STACK:
Well, I think, you know, a lot of public health is about preventing bad things from happening; and it's really hard for folks to connect the dots, just how bad it is if you take that prevention away, right? So it's out of sight, out of mind. And so, it's not seen as a priority, number one.

Number two, public health isn't often flashy, right? I mean, COVID is very, very different. Public health has been in the spotlight in a very unusually enhanced way. So, people are not generally aware of our attendance to it. And the people who benefit most immediately day-to-day and use the services where they are very aware of what we do are often the least advantaged in society, who are vulnerable and unable to advocate as strenuously as those who have more means and positions of authority and financial resources.

It's tough because the people that we serve in our clinic settings and other areas are some of the most vulnerable in society and they're not often set up well to advocate, to persuade others to support this more.

So, it is difficult. It feels like a bit of an uphill battle. But I think COVID has made very clear that there's a crying need to give more attention to public health.

JOHNSON:
The federal government has invested trillions of dollars in the response. How has Kentucky benefited from those investments?

STACK:
First of all, we could have never gotten where we are now—meaning taking care of folks with having access to testing, having access to vaccination, having access to PPE and other resources—we would have never been able to do that without the federal support. So, the federal support has definitely helped in the emergency response.

The federal support also has the potential to help—and it's the intention of our federal partners—that it will help when we look at trying to invest in public health and improve some of these challenges. But it is a boom-bust cycle all too often. There's apparently a rich tradition of chronic underfunding punctuated by episodic crises that result in a relatively large influx of resources after a disaster.

And then, it's very difficult because you don't have sustainable funding. You have these peaks and troughs that make it very difficult to build sustainable, high-performing, reliable systems, and that's the challenge here.

And so, the feds are trying to take some steps to make some of the funding, hopefully—or at least stating their intention to make some of the funding—more stable, but it's going to be difficult over time, right? So, we hope to build ways that the systems we design now—information technology and people—that those are at least sustainable in some measure better than when we entered the pandemic.

JOHNSON:
With all of that money flowing into the state, how do you advocate for local investments when some could look at that and say, "You've got all the federal money you need, we're going to spend our dollars on something else." How do you walk that line with people in Kentucky?

STACK:
Well, with great difficulty. It is hard.

There's always a competition for a limited amount of resources against unlimited demands, right? And you know, we have needs and demands in public health to try to support the population for the state. But so do the people who are educating our children; so do the people who are protecting our houses and our people and our property—you know, with the police and fire departments; so are the people building the bridges and the roads and all the other infrastructure. So, there's countless demands against the limited resource space.

But public health returned many multiples of healthy value, added life years to the population's individual and overall health, and—if it is done well—has the real potential of lifting all boats and raising the water level for all of those other activities if we can invest in keeping our people healthier, hopefully happier, in life and having reasonable chances in life to reach their full human potential.

So, I think we've got to do a progressively better job making our case for why relatively small investments in public health can yield magnitudes larger return on investment over time if our people are healthier and able to be more productive.

JOHNSON:
We know that public health leaders are thinking about how to go from a roller coaster funding approach to one that's built on steady funding streams. What are your thoughts?

STACK:
I wish I had actionable thoughts—I have many thoughts, but whether they're actionable yet at this point is another question.

So, we have a lot of counties throughout Kentucky that are in serious financial distress because they relied on coal and other blue-collar industries, which are no longer there and are not likely to return. And so, there's a lot of socioeconomic challenge in very many parts of this state, which makes it difficult when you rely on a tax base to draw local taxes to support local health departments. So, Kentucky has its own challenges socioeconomically in being one of the less resourced states in the country.

Now, we've had a lot of financial and economic announcements over the last number of months here about investment in the Commonwealth, and employers coming in and building factories and plants and new large places of business; so, I think we have to hope that we can find ways to do social and economic development that can help increase the productivity and opportunity for the people here that then also allow to feed the base of taxable revenue that goes through here so that we can then better support people—and you have a virtuous circle over time, right?

So, you have to kind of get like Jim Collins' Good to Great book that he published years ago—you got to get the flywheel turning somehow and get a virtuous circle of reinforcing benefits. It's very, very hard to get it started in the early days. Once you get it moving, it's seemingly easier to pick up momentum over time.

So, you know, it's going to be hard to find those sustainable funding sources. And I think we all operate under the understanding that the federal support will dry up at some point, and we will again have that cliff financing phenomenon that's so difficult to navigate.

JOHNSON:
Well, how are you preparing for that time when the money could run out, and then how do you build your department so it can survive between that time and the moment when you hope local economic initiatives will pay off?

STACK:
So, as we're building these new activities, I think we're—at least in Kentucky—trying to build them mindful of the reality that, whatever we grow to in the short term in the next couple of years, we'll have to retreat back into a sustainable footprint. So, as we do that, I'm trying to be mindful with our team for which positions are we going to, as we build larger teams, which are the positions we're going to really work very hard to retain when we have to go through an inevitable right-sizing later down the road.

My hope will be, then, that we can make good use of the short-term escalation and resources to get a lot of groundwork done and a lot of processes and other supports in place; and then, a smaller team of folks would be able to maintain some of that activity, maybe in working with partners and partnerships across the state—with nonprofits and corporations and local governments and other agencies.

So again, it's going to be a difficult journey. It has been sort of like a goldfish swallowing a whale. When you look at the relative resources we had, which were constrained but not insignificant, relative to the amount of resources coming in over a two to three-year period—it's been very difficult, I think, for a lot of us in public health across the country to scale up this rapidly and deploy these resources in as organized a manner as we feel we need to, and yet still move at the pace that's necessary.

So, it's been a challenge, but I think we doing so far, a pretty good job here in Kentucky, trying to make the most of that challenge and find the most opportunities within it we can.

JOHNSON:
Basically front-loading some of the work while you have the money, planning for the day when a smaller team might have to assume control of the programs?

STACK:
Right. So, we can buy software and license—this is just an example—software and licenses that require a larger team to install, to import data, to get up and running, but then maintaining it at a steady state takes less energy in the form of resources and financial support.

So, I'm hoping we can do some of that rapid escalation and then get to a comfortable, you know, flying altitude for cruising and sort of keep ourselves there with a smaller resource base in the years down the road.

JOHNSON:
When you talk about these funding questions with your team, what's your message to them? How do you communicate the need to be ready for the day when the money might disappear?

STACK:
I think that's a great question. I think it's actually one of those things—if I'm, myself, sitting at my desk a few months ago and reflecting and thinking, "Wow, you know what? We managed to accomplish some other things despite of—maybe in part, because of, but largely despite of—COVID."

So, when I started out last year, 21 months or so ago, we had vacancies across all sorts of division director positions and branch level leaders, and even in the commissioner's office. And one of the challenges all of us in public health faces is the compensation for the employees is not always the best, and state governments have their own rewards and challenges; and so, it's not for everyone. Not everyone will want to work in state government.

But over the course of this last 21 months, we filled in all the divisional leaders, we filled in all the positions in the commissioner's office. We've streamlined the commissioner's office a little bit and repositioned some of the activities out of the commissioner's office into the divisions where I think they more appropriately reside.

And over that journey, we have managed to break down silos and now have divisions seeing each other as resources and valuable assets, both the teams and the individual people, and actively collaborating with each other across the different divisions and with the commissioner's office. I think what we have done is we've managed to transform an underresourced community of leaders into a nearly fully staffed bench who actually are performing as a high-performing team at this point.

And I think my approach—my message to them is that what they do matters and is important, that there are a lot of people who benefit from what they do, and that I have confidence and trust in their ability and in their potential, and that we are willing to allow them enough latitude to take some reasonable risks in order to achieve really big successes. And when the occasional imperfection or mistake occurs, as long as people have followed a reasonable process and use good judgment, that not succeeding is not the same thing as doing something wrong. In fact, not succeeding is the price you pay to get more things right over time. It means you have to be willing to take some risks and stretch yourself and challenge yourself.

And so, the message to the team that I have the privilege serve alongside has been that it is their health department, not mine because I'm an itinerant commissioner. I mean, commissioners come and go; but most of these other people in public health are there through the commissioner transitions. And my goal has been, and my focus has been, to invest in that team and try to support them and help them feel empowered to help transform public health in Kentucky to be the higher performing system that we hope and believe it can be.

And so, that's been a big part of the journey, but I think it's also beginning to show some of the fruits of success at this stage for the accomplishments that I think we have done and the ones I hope we'll do in future.

JOHNSON:
For 10 years, Janet Hamilton worked as an epidemiologist, holding several titles in the Florida Department of Health. Today, she advocates for her colleagues as executive director of the Council of State and Territorial Epidemiologists. Like everyone else in public health, the people that you represent have been stretched to the max during this pandemic.

HAMILTON:
Oh my gosh, incredibly so. I mean, I think this pandemic has brought epidemiology to the forefront and the key role that it really plays and how really transforming data to action is the foundation of all public health responses.

JOHNSON:
We hear a lot of talk about data and how sometimes it works and sometimes it doesn't. Sometimes systems talk to each other; other times, not so much. How have we fared in that category throughout the course of this response to the last two years?

HAMILTON:
I think that is such a great question.

There are some bright spots out there for sure. We've seen some really amazing improvements in electronic laboratory reporting—and that was really starting before the pandemic. We've also seen some great advancements in electronic case reporting.

But I think where we still have lots of opportunities is really working between public health and healthcare to approach it in a much more seamless and interoperable way.

JOHNSON:
Of course, those sorts of fixes take funding, and there has been a lot of focus on money during the pandemic—how to get dollars out to the field so that everyone working on this response can do their jobs and try to keep people healthy and get this virus under control.

Let's go back in time, before we talk about what's been happening in the last two years, and talk about funding and how things changed in this world after 9/11. Can you bring us up to speed? Remind us about that.

HAMILTON:
I think it's really important for us to look back because we have so many lessons learned.

When we think back to how public health has evolved and been funded, I would say historic events like 9/11 are defining moments for public health. Just as this recent coronavirus pandemic has also shifted demands, events like 9/11, COVID-19, H1N1—they are transformational.

And I would say, historically, what we see is that public health is underfunded. Then, we have a major event and funding comes in and that funding is there really as an inject to support some of the critical and crucial gaps, but often it's just a short-term, response-specific approach. And we really haven't seen a broad-scale, long-term commitment to funding the public health infrastructure.

9/11 definitely put preparedness onto the map for public health, and we saw the formation of the Public Health Preparedness cooperative agreement. But we have sadly seen over time, as well, that those monies have become less and less.

JOHNSON:
And you welcome those investments when they do come—they're needed and they result in work moving forward—but it's just no way to run a railroad really, is it? I mean, eventually the money runs out and things go back to the way they were.

HAMILTON:
I think you're exactly right. In that sense, we really need approaches for public health that are sustained, sustained at a much higher level, and over the long term; because health is a long-term commitment, and investment in that for the entire population takes time.

And, as you have well pointed out, what tends to happen is that we fund public health in some type of specific siloed way, and we're really not able to build those interconnections in the way that we would like.

JOHNSON:
And the money is flowing right now, again, in the trillions of dollars. But is there worry it'll run out, that we'll be right back where we were after 9/11?

We've got all this funding right now and, a year or two from now, it'll all be gone and things will start to roll backwards?

HAMILTON:
Absolutely. I mean, this waterfall approach or monsoon approach is very hard for public health to respond to. It's like—you know, when you think of dry lands, and then lots and lots of monsoon rains come, and you get mud and you know, a lot of runoff, but not necessarily the ability to build that structure that you would truly like to have. And I think we're already seeing that in public health.

And I think there's been a fair amount of criticism without the recognition of how challenging it is and how important it is that—especially when we see something that now accounts for the most morbidity and mortality in any specific jurisdiction—that we're not having more of a long-term commitment and sustainment to our public health infrastructure.

JOHNSON:
Specifically from your vantage point, representing the epidemiologists, what are the things that you think would be better addressed if the funding could be more regular, more predictable?

HAMILTON:
I think there's two major areas that we think about, and it's the epidemiologists—the people and the people that work within the public health system—and then also the data systems themselves. And both of those are core pieces of infrastructure—so epidemiologists, public health informaticists, data scientists, but then the systems that move the data that collect the data and also rapidly allow for various types of visualizations to occur. And I think we have never really seen a sustained commitment in investing in epidemiologists or in our public health data infrastructure.

JOHNSON:
Talk about the equipment that labs use, that public health departments use.

I'm thinking back around 9/11, I had a flip phone; and now, during the pandemic, I have a very sophisticated 5g mobile device. The same can be said for the gear that you're using to try and address all of these viral issues. Isn't it the same?

HAMILTON:
I think it's very similar. We really have to build our data infrastructure in a way that all different kinds of traffic, data traffic, can be moved. So, just like our interstate highway system moves lots of goods and transports many things that are packaged in different ways, but there's all different kinds of cars that move across that infrastructure—that's the same thing that we need for our data and our data infrastructure.

So, whether we're moving data out of hospitals around hospitalized individuals, whether we're moving data around laboratory reports, or also having the ability for public health to gather some of its own data—that piece of a case interview or a case investigation where you're really drilling down and talking to people about when and where and how they may have been exposed—are critical components.

And that's not captured in our healthcare infrastructure, but it is something that public health spends a lot of energy collecting. And now, our data infrastructure needs to integrate all of those components so that we can really have the information that we need in order to be able to create good policies, but also to elevate those critical components for behavior change.

JOHNSON:
Thinking about how the system has been working throughout these roller coaster periods of funding or no funding, how are epidemiologists around the country, in the states and territories, how are they working with the current system?

HAMILTON:
Well, I'll say, how are they working with it? I mean, we've seen staffing increase broadly across the board, but I think what they're really working to do is to think about how can they invest in long-term ways. And I would say one thing that I would really encourage people to continue to think about is how can they identify and invest in cross-cutting types of infrastructure.

And that's what we're really thinking about at CSTE, is how our data infrastructure is not disease-specific, but is truly disease-agnostic.

JOHNSON:
Does the same go for enhancing and then maintaining a higher level of lab capacity?

HAMILTON:
So, you know, lab capacity is one of those really key specific components. And there are different types of lab tests and different types of technology that have to be maintained by disease as well as by, you know, what you're looking for—is it a DNA test and a PCR test, or is it a culture where you're actually growing the organism?

So, there's lots of components in lab; but the way that we move lab data to the epidemiologist, that's a base infrastructure that needs to be not just specific for any one disease, but support all of the different diseases and pieces of information.

There's been a lot of focus on COVID but actually, from a laboratory perspective, COVID is a lot simpler than a lot of other diseases that are under public health surveillance. So, really using the lab infrastructure, of course, to support this immediate need, but to support infrastructure and sustainment of those lab information systems long into the future and getting the data to the epidemiologists to do disease investigations is really critical.

JOHNSON:
It's likely people who are listening to this conversation right now already know what the Epidemiology and Lab Capacity cooperative agreement is, but let's just pretend that somebody doesn't—including yours truly.

Tell us what that is, and then we'll follow up a little bit with that to understand how that's informing the way forward.

HAMILTON:
Yeah, absolutely. So, the Epidemiology and Laboratory Capacity cooperative agreement, or ELC, has been a foundational component of supporting exactly what its name entitles—epi capacity and lab capacity—for many years. And it is a funding mechanism that goes to all the jurisdictions, all state health departments, territories, and then some large local health departments.

What we have seen in the pandemic is a lot more funding coming through the ELC grant than what we have seen in the past. And you know what I would say as well, it has been a foundational component for many years—it never was able to support the broad needs of state health departments. And so, it has been really nice to see more dollars coming through that have a specific focus on epi and lab.

JOHNSON:
It's been a convenient mechanism to get the money out the door quickly, given what we're up against right now.

HAMILTON:
Yes, absolutely, and it has been in place with a governance structure that is multifaceted, and that has been another critical piece to assurance that the money is able to be used in the right places.

JOHNSON:
Have you thought about whether that system needs to be modified? In the perfect world, would it be something different going forward?

HAMILTON:
Well, I think focus for epi and lab is going to need to be retained in whatever world, because we know that diseases don't follow borders and they—you know, just like we've saw the emergence with COVID-19 and the coronavirus, you know, we will see other diseases emerge as well. A handful of years ago, we were thinking about Zika, and the ELC grant did support the Zika response. So, I think there will always be a need for evolution.

One thing that I think will be critical, is critical now, is that we really look a little bit less on components—and the ELC grant has evolved to have many components now—and evolve to ensure that we have more dedicated funding and cross-cutting capacities—cross-cutting epidemiologists, cross-cutting support for data systems. To me, that's where the future of ELC really needs to focus.

JOHNSON:
Is that what you're hearing also from your members who are out there trying to make these grants work and thinking, "Wow, this could be better. There's another way to do this." Is that what you're hearing from them too?

HAMILTON:
Absolutely. I think, you know, everybody recognizes that there's a need to support and focus on COVID; but if we can't support other disease areas, that just leaves many gaps.

And there are so many touch points, as well, that COVID-19 has brought forward. So, what are the touch points now that support things like mental health issues and how we do better epidemiology for mental health? What about substance use? What about, you know, how we do a better job of looking at maternal and child health issues?

And so, it's not just one disease. And I think, just like our health is not made up of just one specific component, and assuring that, you know, we have an approach that's more like a rising tide lifts all boats.

JOHNSON:
You're watching all of this from the association level—keeping track of what's happening in Washington, sending those alerts out to your members, giving their feedback to people on the Hill, and such. What are you telling them about the current environment as it relates to the way this cooperative agreement is run—what might happen there, funding levels, all of the talk going on about some sort of new investment coming by the end of the year—what's your message to the members right now?

HAMILTON:
I think the focus needs to be on how we really use this opportunity to truly transform public health. I think we have so many dedicated individuals that have worked in public health for so long, and it does feel like we have an opportunity in front of us that is bigger than what we have ever had before. And we have seen some major and transformational investments already in the public health system from Congress, but really looking towards those dollars coming down in a way that supports true building of our public health infrastructure.

And so, you know, time will tell how this evolves. I think CSTE and ASTHO, as well as the other major public health associations, are really focused on this broad, systems-based approach and really communicating that to Congress and that specific need. And I just really encourage membership to think as creatively as they can. So, with whatever dollars that come down, how can those dollars be used not just to support COVID, but to really think about, "Well, if COVID-19 is a respiratory disease, this means I can be building infrastructure for all respiratory diseases. If COVID-19 is associated with outbreaks, how am I building my infrastructure for all outbreaks?"

And I think—and hope—that we will see some more commitment to support public health in that long-term way.

JOHNSON:
Thanks for listening to Public Health Review.

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For Public Health Review, I'm Robert Johnson. Be well.