The Fund supports networks of state health policy decision makers to help identify, inspire, and inform policy leaders.
The Milbank Memorial Fund supports two state leadership programs for legislative and executive branch state government officials committed to improving population health.
The Fund identifies and shares policy ideas and analysis to advance state health leadership, strong primary care, healthy aging, and sustainable health care costs.
Keep up with news and updates from the Milbank Memorial Fund. And read the latest blogs from our thought leaders, including Fund President Christopher F. Koller.
The Fund publishes The Milbank Quarterly, as well as reports, issues briefs, and case studies on topics important to health policy leaders.
The Milbank Memorial Fund is is a foundation that works to improve population health and health equity.
October 27, 2022
Population Health Health Equity
Richard F. Callahan
Nov 29, 2023
Nov 13, 2023
Oct 25, 2022
Back to The Milbank Quarterly Opinion
In a recent Milbank Quarterly Opinion, Bajaj and colleagues highlighted how federal funding for infrastructure might advance health equity. Based on professional experience with infrastructure funding, planning agencies, and research, I would like to suggest an alternative and more expansive view on engaging public health in the infrastructure funding bill.
President Biden’s Coordinator of Infrastructure describes the recent Bipartisan Infrastructure Law as “…historic in its size – the largest ever investments in broadband, rail and transit, clean energy, and water, to name a few – as well as the breadth of programs and sectors included in the law. The infrastructure law allocated funding to over 350 distinct programs across more than a dozen federal departments and agencies.”
Focusing on past land use, zoning, housing financing, and infrastructure failures can inform future action. Still, analysis needs to be expanded to identify successful infrastructure cases and institutional designs that have advanced health equity. Addressing racial and health inequities through infrastructure investment calls for carefully identifying:
Two of the fundamental public health lessons from the COVID-19 pandemic responses are that: 1) the credibility of public health practices is contested, and 2) key COVID-19 responses were inherently intergovernmental. Drawing on built environment examples not related to past infrastructure funding processes can undermine the credibility of public health. Overlooking past successes in advancing public health fundamentals of clean water, clean air, and toxic exposure mitigation limits the potential for designing more effective institutional responses.
While significant historical inequities exist in public infrastructure, there have been successes in expanding transit, improving water and air quality, and other outcomes for marginalized communities. Building credibility in the discussion on infrastructure or any public health issue calls for avoiding generalizations while advancing the most rigorous understanding of the current system to better identify areas for change.
Another limitation of current public health discussions is treating infrastructure funding and implementation as an exclusively top-down, federal-driven process. The federal focus overlooks the innovations and impact of counties (see, for example, https://napawash.org/academy-studies/national-association-of-counties-federal-assistance-and-innovative-counties), cities, states, tribal, and territories. Public health is a highly decentralized system reliant on a high functioning intergovernmental system. In addition, the Metropolitan Planning Organizations (MPO) are central to the infrastructure approval process and other funding plans, as well as their impact. For example, as an MPO, the Southern California Association of Governments, shapes infrastructure available to more than 22 million residents. An important starting point for public health advocacy recognizes that the current system is NOT unidirectional from federal to state. Moreover, there is limited federal government capacity for “whole of government” actions. In responses to COVID-19, federal actions occurred under specific legal authorities, such as the Defense Production Act, the Stafford Act, and Emergency Use Authorizations, with capacity to act distributed among agencies, such as the Department of Defense, the Centers for Disease Control and Prevention, and the Food and Drug Administration.
A challenge in advancing health equity through infrastructure funding is the limits of current practices of categorical grants formulated in ways that inhibit and lack incentives for local, regional, and state governments to develop the strategies and structures needed for integrated solutions across funding and programmatic silos. Moving from a top-down approach, with Congress determining where to spend the funding, to increased discretion for local government and community decision-making aligns with the starting point for all effective leadership: engage people closest to the problem. Local decision-making and community engagement create shared responsibility and ownership for achieving results. A top-down focus limits insights into the current system’s complexity, failing to identify the range of leverage points for effective change to advance health equity.
A deeper appreciation of the intergovernmental system for infrastructure building can tap into two potential strengths of public health professionals: partnership building and interdisciplinary problem-solving. Advancing health equity does not call for asserting public health primacy, but rather for public health partnerships. Intergovernmental systems address the most complex societal challenges in the United States. These complex problems defy solutions from any single academic discipline or professional field1 and exceed the capacities of the federal government acting alone or of any single level of government. An interdisciplinary approach facilitates societal problem solving most effectively when drawing on multiple disciplinary and professional perspectives and varied models, not when advocating for the supremacy of one approach.
Increased understanding of past organizational and institutional design successes can be a starting point for improving policy design and implementation practices across a wide range of “wicked problems.2 Two examples of federal legislation contributing to local successes illustrate the point. The Alameda Corridor rail project provided multiple benefits to marginalized and vulnerable communities: reduced truck traffic congestion, reduced air pollution, contaminated underground water clean-up, a job training program for economically disadvantaged communities, and specific local benefits.3 The success of the Clean Air Act in the Los Angeles Basin over the past four decades4 offers institutional design insights for improving air quality that can be applied to future infrastructure funding to address the disproportionate health impact on communities adjacent to high traffic areas.
Both examples emphasize the need for institutional designs that extend beyond one goal in order to advance a range of health, community development, and economic concerns in partnership. For example, regulatory flexibility, incentives, federal match, or other mechanisms are needed to structure into law more effective approaches to advancing health equity. A study of past infrastructure successes highlights the importance of finding leverage points for effective action in new legislation. An example is the definition of disadvantaged communities for funding opportunities.
In their opinion piece, Bajaj and colleagues asserted that “…current efforts are limited in scope and require a revised framework with an explicit focus on health equity and environmental justice.” However, the current limits of long-standing requirements for considering health and environmental impacts in the National Environmental Protection Act or the Metropolitan Planning Organizations (MPO) are left unidentified. How have those requirements for community engagement not worked since enactment over the past 40 years, and have state requirements, such as in the California Environmental Quality Act, been ineffective? Public health discussion of past practices should identify why the current system does not advance health equity or why the community participation requirements in various federal laws have not worked.
The expectation that the new infrastructure funding is positioned to continue business as usual is an informal statement of the challenge for institutional design to move from existing path dependencies. But a reflexive, default assumption that current funding ignores health equity overlooks the current focus on “…supporting disadvantaged and underserved communities, advancing climate resilience and sustainability.”
The COVID-19 pandemic has highlighted the need for building credibility in communicating public health recommendations. Credibility starts with a deep understanding of the limits and strengths of past infrastructure funding efforts on advancing health equity and on protecting vulnerable and marginalized communities. Expanding public health credibility begins with building partnerships, not asserting the primacy of public health professionals over all other professionals. Three action steps can advance the impact of public health research, best practices, and aspirations in leveraging infrastructure funding to advance health equity:
The recent infrastructure bills offer opportunities to listen and build coalitions that address infrastructure-driven health inequities. In the contested discussion, the starting point should be the empirical reality, not generalized assertations. The societal significance of aligning infrastructure funding with advancing health equity shares the same starting point of other successful public health efforts – grounded in credible research on the current realities, with actionable recommendations for leveraging assets into improved, measurable equity outcomes.
Rich Callahan leads TAP International, a consulting firm for training, analytics and program evaluation for local, state, and international governments. He is also a full-time professor at the University of San Francisco (USF), with a joint faculty appointment in both the School of Nursing and Health Professions and the School of Management. He is co-director of the MPH-Health Policy Leadership concentration at the USF Sacramento and Academic Director of the Master of Public Leadership, USF Washington, DC. campus. Mr. Callahan’s presentations, research, teaching, and consulting focus on strategies and leadership behaviors that are effective in complex, demanding, and dynamic environments in the public and nonprofit sectors. He has taught, designed, and delivered leadership programs for elected and appointed officials in state and local government for over 20 years
Get the Latest from the Milbank Memorial Fund
An endowed operating foundation that engages in nonpartisan analysis, collaboration, and communication, with an emphasis on state health policy.