Amid low rankings, Indiana eyes $240M increase in public health spending
Jan. 28—INDIANAPOLIS — 35. 38. 41. 40. 41. 13.
No, those aren't this week's Powerball numbers. They're the state of Indiana's various health rankings — mental health, infant mortality, early adult mortality, obesity, smoking and suicide, respectively — according to US News and World Report's 2021 "Best States" rankings.
In all, the media company ranks the Hoosier state 40th in overall health.
More troubling, though, is that Indiana's health rankings have gotten worse over the last few decades. In 1991, the state was ranked 26th in the nation by U.S. News and World Report.
So what's to be done?
In August 2021, Gov. Eric Holcomb created the Commission on Public Health, ordering it to meet monthly to study the state's public health system and draft recommendations for improvement.
Last year, the commission — made up of various state health officials and leaders, former elected officials, county commissioners and other elected officials — released its report.
More than 100 pages in length, the report covers six concerns — emergency preparedness, public health funding, governance, infrastructure and services, workforce, data and information integration, and child and adolescent health — and issues a total of 32 recommendations.
The most notable recommendation: The state should budget more than $240 million a year to bring Indiana in line with spending across the nation on health care.
PUBLIC HEALTH FUNDING
You get what you pay for. It's an old adage, but it's true when it comes to public health.
Perhaps the most shocking finding of the commission is that public health funding in Indiana is "chronically underfunded."
In 2018-19, before the pandemic, funding from the state and the U.S. Centers for Disease Control and Prevention per person in Indiana averaged $55. That's significantly lower than the $91 per person average nationwide and ranks the state 48th. America's Health Rankings' 2021 report ranked Indiana 45th.
In addition, many local health departments spend less per capita on public health than the national median. For example, Howard County spends about $15 per person, Vigo County spends about $25 and Madison County spends just under $10 per person. Only two counties — Marion and Brown — spend more than the national median of $41 per person.
The chronic underfunding of public health has had devastating effects.
Life expectancy in Indiana has begun to decrease after decades of upward trajectory and, since the mid-1990s, has trailed the national average. The state's life expectancy peaked in 2010 at 77.5 years and has largely been in decline since. Indiana's life expectancy of 77.1 in 2018 is 1.9 years lower than the U.S. average and places 40th nationally. Researchers attribute the decline primarily to substance abuse.
Financially speaking, Hoosiers' poor health is costing the state and its businesses and residents billions of dollars, according to the governor's commission on public health:
—Obesity and diabetes account for more than $8.4 billion in productivity losses
—Chronic diseases, such as heart disease, cancer, lung disease, stroke, diabetes and kidney disease, are among the leading causes of death with total indirect costs of $75.5 billion a year
—Smoking results in nearly $3 billion in annual health care costs each year, including $590 million in Medicaid costs.
The recommendations from the commission all point to this: More public money needs to be spent on health care in Indiana.
Specifically, the commission recommends that the state increase its per capita spending from $55 to $91 to match the 2019 national average. The commission also advises that the state adjust its public health spending for inflation to ensure "long-term improvement in health outcomes through consistent programming."
The onset of the COVID-19 pandemic presented many challenges to Indiana's public health system. The pandemic exposed the need for a centralized way for both the public and officials to see timely COVID-19 data, such as infections, deaths and testing numbers.
To fix that, the Indiana Department of Health quickly developed connections statewide to collect, verify and disseminate information. The result was an online COVID-19 dashboard with county-by-county information.
While the governor's commission noted that the dashboard highlighted how much the state could improve the timely sharing of information among multiple agencies, including local health departments, the state health department and Family and Social Services Administration.
"In the current environment, there is little coordination between entities and data are stored and transferred in different formats with different privacy and security protections and access and use restrictions," the commission wrote.
"Coordination across these entities has little overarching direction, and there is no process to build consensus for priorities for investment in public health and data resources."
The commission found, for example, that more than half of the state's local health departments do not have the ability to access important data related to social determinants of health, communicable diseases, trauma and more. Nearly 80% of health departments reported the need for data analysis support.
Notably, the state health department has begun a digital transformation project aimed at creating a centralized data and analytics platform and improving data access. In addition, the commission recommends "district-level data services" that support "cross-county analysis," allowing local health departments to access and analyze all data available.
The reaction among public health officials to the commission report has been overwhelmingly positive, according to Dr. Gabriel Bosslet, an associate professor of clinical medicine at Indiana University.
"When I read that report, I was floored with how good it was," Bosslet said.
Gov. Eric Holcomb has championed the report and has made it one of his top priorities for the current legislative session, where the state's next biennial budget will be created.
Some elected state leaders, though, balked at the commission's recommendation of an additional $243 million annually in public health funding, despite the state's $6.1 billion in reserve.
"I found (it) a little bit difficult to swallow," GOP Senate leader Rodric Bray said in November.
State Sen. Ryan Mishler, who leads the budget process for the Senate, said the General Assembly will have to "take a hard look" at any additional funding for public health care.
After the mixed response from state budget leaders, Holcomb is pursuing $120 million in fiscal year 2024 and another $227 million in fiscal year 2025 for health care. If that request is approved by the General Assembly, it would mark a significant increase in state contributions to public health.
Local health departments rely heavily on property tax revenue and grants from the Indiana Department of Health for their funding. The health departments do receive some additional, flexible funding each year from the state government through the state's Local Health Maintenance (LHM) Fund, but that fund is budgeted at only $6.9 million for the 2022 — 2023 biennium.
Under the proposal from Holcomb, 80% of the additional funding would replace the LHM.
Holcomb argued that increased public health funding is needed to help improve Indiana's poor national rankings in areas such as obesity, smoking and life expectancy. He said it will take "new action to get new results."
"Nearly all of these dollars will be deployed locally, in your districts where our fellow Hoosiers need them, tailored to the unique circumstances of each community partner," Holcomb told lawmakers during his annual State of the State address in January.
Several health care bills have so far been filed for this year's General Assembly. One of the most ambitious, Senate Bill 4, authored by state Sen. Ed Charbonneau, R-Valparaiso, seeks to restructure the public health system.
A provision of that bill would funnel money to local health departments across the state via an 80-20 state-local match. Local governments could choose whether to participate. The amount of money one county receives would be calculated based on a per-capita system and social vulnerability index.
How much the state would offer for the 80-20 match has yet to be decided.
"Where we end up going will be resolved as we go through the budget process," Charbonneau told the Indiana Capitol Chronicle.
Bosslet hopes the General Assembly aims high.
"If the legislature decides to move forward with this funding, this will probably be Holcomb's legacy," he said.
Tyler Juranovich can be reached at 765-454-8577, by email at firstname.lastname@example.org or on Twitter at @tylerjuranovich.