MSLN Virtual Convening of State and Local Public Health Leadership: Politics and the Public Health Workforce

Milbank State Leadership Network
Focus Area:
State Health Policy Leadership

EVENT DATE: July 21, 2023


Morgan McDonald, MD, Milbank Memorial Fund
Michael Sparer, JD, PhD, Columbia University Mailman School of Public Health
Lawrence Brown, PhD, Columbia University Mailman School of Public Health


This virtual convening on politics and the public health workforce with Drs. Michael Sparer and Lawrence Brown of the Columbia University Mailman School of Public Health included invited state and local health policy leaders from Indiana, Kentucky, Mississippi, New York, and Washington. The researchers discussed their Commonwealth Fund-supported study, Politics and the Public Health Workforce: Lessons Suggested from a Five-State Study, on building bipartisan support for public health. This was based in part on visits to these five states to examine the distribution of American Rescue Act public health workforce funds, as well as state-based initiatives.

Dr. Sparer gave an overview of The Milbank Quarterly research, highlighting key obstacles to rebuilding the public health workforce. Obstacles included the siloed and time-limited nature of federal funding, complicated civil service hiring rules, competition for workers in other segments of the health care system and required approvals from elected officials prior to spending the funds. In addition to obstacles, he presented the study’s key policy points:

  • The public health system relies on an inadequate and inefficient mix of federal, state, and local funding.
  • Even with more funding, we will not solve the nation’s public health workforce crisis until we make public health a more attractive career path with fewer bureaucratic barriers.
  • Various state-based initiatives suggest that a promising path to bipartisan support for increased public health funding is gaining the support of local elected officials by providing state (and federal) funding directly to local health departments, with performance strings attached.

Creating Political Appeal for Better Public Health Infrastructure

Dr. Brown facilitated a discussion about how to make public health infrastructure politically appealing. Participants from Indiana shared how listening campaigns around the state helped them to build relationships and identify common ground on bipartisan issues like opioids, mental health, and children’s health. Indiana officials noted that allowing counties to opt into funding created ownership and buy-in for public health. Participants from Kentucky and New York echoed the importance of appealing to both local leaders and state legislators to focus issues on the community-level and avoid partisan lines. A representative from Oregon commented on the value of maintaining relationships with local and national businesses that were cultivated during the pandemic to keep the business community involved in community health and safety and their importance to economic development. State leaders from Washington discussed the need to raise the value proposition of public health by showing the return on investment, so that citizens and elected officials recognize the important role of public health in everyday life.

Policies to Facilitate Bipartisan Dialogue

Dr. Sparer led a discussion about policies and practices that can facilitate bipartisan legislative decision making. A representative from Washington discussed the importance of finding bipartisan champions of public health and using messaging that is universally understood and that creates an expectation of public health similar to expectations of public safety. Stakeholders from New York and Indiana agreed and highlighted the importance of using data to connect public health with economic stability and success. Stakeholders also discussed the importance of clear and cohesive public health messaging across regions and across the country, emphasizing that citizens in every state deserve access to basic public health.

Structure to Enable Public Health Investment and Local Decision-Making

Dr. McDonald led a discussion of the resources and support needed for public health investment at the state and local levels. States and localities often have different public health structures, and state leaders explored how to navigate these structures to ensure adequate financing. Participants agreed that engaging local decision makers—including officials at the state, tribe, county, and city levels—was key to success. Participants also observed that engaging both public and private interests, and the medical community, creates momentum for public health investment.

The Effects of (de) Centralization on Public Health Departments

Participants explored the effects of centralized public health systems on garnering local support. In a centralized public health system, the state health department directly operates all local health departments, while decentralized systems have autonomous local health departments. According to participants from Mississippi, the centralized system does not incentivize local officials to engage in public health decision-making, leading to disinvestment at the local level. This places strain on the state, where officials and participants must engage local voices, such as elected leaders and business owners, to reach consensus on public health investment. However, their centralized system has created an opportunity for Mississippi to create regional infrastructure and operational efficiencies.

The Role of Public Health Associations

Participants agreed that public health associations can play a key role in garnering bipartisan and local support for public health; however, not all states have public health associations. Public health associations work alongside state and local government to advocate for public health investment by conducting research, hiring lobbyists, and engaging with legislators and officials. Public health associations can provide valuable direction in public health policy, identifying best practices and supplying technical assistance at the state and local level. Public health associations not only play a role in defining public health strategy, but also advocate across different sectors, participants said. Public health associations bring together multiple stakeholders, including local health departments, tribal health departments, state legislators, medical associations, and business interests.

Overview of Factors Affecting Public Health in the Five States Studied

StatePublic Health System StructureState Public Health AssociationParty Control of State Government
New YorkDecentralizedYesDemocrat

Lessons Learned

Key takeaways from the discussion included the following:

  • Bipartisan support for public health involves engaging many different actors at both the state and local level, including local businesses, community members, and tribal nations.
  • Stakeholders need to have a sense of ownership over the policy. Public health associations play a key role in promoting best practices in public health and sharing the benefits of public health investment across political parties.
  • Public health advocates should frame public health as an aspect of public safety and help local health departments to establish “what public heath means” for their community.
  • Communications strategies should focus on creating a shared understanding of public health. This includes adapting public health jargon as needed to avoid language that can be polarizing.