WTHC Season 2 Episode 6 Transcript

Public Health, Politics, and Money: Lessons from Kentucky and Indiana

In March 2021, in the midst of the pandemic, Congress appropriated $7.6 billion to state and local health departments in an effort to strengthen and stabilize the nation’s public health workforce. With a colleague, I received a grant to follow the money, the politics, and the impact of that program.

We decided to focus on five states: Indiana, Kentucky, Mississippi, New York, and Washington. Five years later, I’m still following the money, from DC to the statehouse, from the statehouse to the county commissioner, from the county commissioner to the public health nurse.

As this story has evolved, I’ve looked particularly closely at two of these states, Kentucky and Indiana, both of which recently increased state funding for their local health departments, drawing lots of national attention for their reform initiatives. At least until this past April, when Indiana reversed course and slashed the funding for its reform by 70%.

So, how did these two states manage to get more money for their PH departments? What happened once they did, and, in the case of Indiana, what happened when all that extra funding got pulled?

From the Center for Public Health Systems at Columbia University, this is “Who the Health Cares,” a podcast about the history, politics, and substance of our public health system. I’m your host, Michael Sparer.

But on today’s episode, I’m handing the mic over to my colleague and friend Rebecca to interview me about the work I’m doing in these two states, to talk with me about public health, about money, and about politics.

Becky: Hey, Michael. Thanks for having me.

Michael: Thanks for taking on this role.

Becky: I like being in charge of the conversation.

Michael: Becky, where should we start?

Becky: Well, before we jump into the story, why don't you start telling us a little bit about your background. I know you've spent your career working, researching, sort of understanding and talking about Medicaid.

Michael: Yeah, I've spent over 30 years here at the Mailman School, and several years as a lawyer before that, really studying and writing and thinking about primarily coverage and cost and programs that are designed to provide increased access to low-income populations, such as Medicaid and the Affordable Care Act, and programs that are designed to deliver services to them.

I started doing that as a lawyer for New York City, uh, before I even went back and got my doctorate in political science. But certainly, since I've been here at Mailman, I've spent much of the last 30 years focusing on programs like Medicaid.

Becky: So what was the impetus behind your five state study?

Michael: Well, you know, it's interesting. I had realized, first of all, I'd been in a school of public health for over 30 years, and I knew remarkably little about how the public health system actually worked on the ground, uh, which I think is a failing of many of us here in schools of public health. We don't really know how it works on the ground.

And in addition to that, we were in the midst of a pandemic. And quite honestly, I woke up one day and I saw a newspaper story about the American Rescue plan appropriating almost eight billion dollars to try to rebuild the public health system in the United States. And I thought, "I'd really like to learn more about that." I mean, I've always been interested in how money flows and how legislation is implemented, and what happens when there's an appropriation in DC that goes to the state, that goes to the counties, then that goes to people on the ground. And I thought, “This is made for me to study. Let me try to follow the money." Uh, so I was able to get a grant to study it, and I was off and running.

Becky: And what can we learn from following the money?

Michael: Well, I mean, there's a huge distinction between legislation being enacted in Washington, DC and how it's implemented on the ground in local communities and there's always this sort of iteration process in which things change. Nothing works as you would expect it to work as it's written on a piece of paper. And so I didn't know what we were gonna learn. I had no idea what we were gonna learn, but that was sort of the exciting part of the project. Was this legislation really gonna achieve its goals or not? Would this infusion of funds help state health departments to provide the kind of care their communities needed but so far weren’t getting?

Becky: Yeah, great. And so why these five states? What was special about these five states?

Michael: You know, that was probably one of the most difficult things that we had to figure out how to handle. You know, there's 50 states, there's over 3,000 local health departments, there's tribal units, there's territorial units. There were gonna be lots of units that were gonna get some of this money. Who should we pick and why?

We wanted to have more than two or three, but less than six or seven. We said, "Okay, five." New York was relatively easy. We're here in New York. We know the players. We'd start there. What would our other four be? Uh, I worked with colleagues on this a lot. We wanted some geographic diversity. We wanted some political diversity. We also wanted some organizational diversity because some state health departments are very centralized, the state runs everything. Some are very home rule, they're run really at the local level. So we wanted organizational diversity.

And we also, to tell you the truth, and this is sort of what I never put in the, the research papers, we wanted states where we thought people would actually talk to us and talk to us fairly. So before we settled on and finalized a state, I had a conversation with the health commissioner in each state, and I said, "Here's what we wanna do. In order for this to really work, you're gonna have to tell your team to talk to us."

I mean, Mississippi, Columbia University professor goes down to Jackson, Mississippi, to talk with people about how they're implementing a law, people are gonna question that. So we had those conversations. So out of that, we ended up picking Indiana, Kentucky, Washington, New York, and Mississippi.

Becky: So what did you learn?

Michael: That's the $64,000 question, or in this case, the $8 billion question I guess you'd say. Um, let me just tell you what we did a little bit.

Becky: Okay.

Michael: You know, we spent at least a few days in each state, spending at least one day with state health officials, and then traveling to local health departments in each state, and also trying to talk to as many people as we could about what was going on. We also tried to look at data, you know, where they were spending the money, how they were spending the money, et cetera.

One of the things that we learned was that none of the states, none of the five states, was able to spend all of the money it had been appropriated for at least the first two years of the program. They did some good things with some of the money, but they couldn't spend it all.

The question then is, why? Uh, there were many, many obstacles. In many states, including a couple of ours, civil service rules make it hard to easily hire new people. You gotta get around these civil service rules. You gotta figure out how to hire. That takes time.

There was a pandemic going on. We had overburdened state and local governments. And in many states, the notion of increasing the size of the public health workforce at the very moment that the public health workforce was being accused of violating people's rights and making them wear masks and take vaccines, et cetera, was controversial.

There also was competition. You know, public health jobs are low-paying jobs, generally speaking. A public health nurse can typically make a lot more money, um, working for a hospital than she can for a health department. And then if that all took a year, this was a two-year piece of money that they had, then you're hiring someone, you can only guarantee them eight, nine months of a job before the funding is out. So why would someone take that job? So it really... the fact that they accomplished as much as they did with the money is almost a testament to their resourcefulness as opposed to, you know, a failure of the project.

Becky: So I know you’ve taken multiple trips to some of these states at this point, but after your first trip, what did you learn?

Michael: Yeah. It's interesting. As it turns out, while we went in with the expectation that the primary focus of the study was gonna be how the states were spending the ARP funding, and that became, and it was, a primary focus of the study. As we got into those states, though, and as we started talking to people, we realized there were lots of other things going on that were really interesting in those states.

And in particular, we realized that we were entering Indiana, for example, at the very moment that Indiana was having this conversation about whether or not the state should be increasing funding for its local health departments.

And when we entered Kentucky, we realized that Kentucky had just, a couple of years earlier, enacted this major expansion of their state funding for local health departments in an interesting way. And so that became sort of a second story that we started to look at.

Becky: So, I mean, I wanna get into the Kentucky and Indiana story, and maybe we'll start with Kentucky.

Michael: Sure.

Becky: Maybe talk a little bit about what prompted Kentucky to consider the health reforms. Like, how were they thinking about it when they initially got the money?

Michael: Sure. One of the things that is interesting about it is there's, I don't know, 61, 62 local health departments in Kentucky. But it's what's called a mixed model state, in which the way it's organized is there are certain tasks that the local health department does, there are certain tasks that the state does. And they work pretty well together, the local government and the state in the state of Kentucky.

So they were in a situation where they had an association called the Kentucky Health Department Association, or KHDA, that was organized, and they had good relationships with the state.

And then in the years around 2010, '11, '12, some problems started emerging in the market in, in kentucky, in the local health market department. One problem that emerged was their public health workforce was aging, and there were a lot of retirees. People were starting to retire.

And they had a pension system which provided what's known as a defined benefit pension if you retired. So if you retired after working for a number of years, you got a percentage of your salary as a pension. That's a very expensive kind of pension. And the more the system was in a little bit of financial trouble, the more people were encouraged to retire 'cause they wanted to get their defined benefit pension before the money was gone. So they had a pension crisis.

They also had a situation where they used to provide a lot of clinical care services, the local health departments, to community members, and they would generate Medicaid revenue from doing that, and that was a big source of revenue.

Public health in general and in Kentucky started to say, "Maybe we should be moving out of the clinical care business, let the community health centers deal with that," particularly after the Affordable Care Act, was enacted in 2010 'cause there was more of an emphasis on coverage and so on and so forth, community health centers. And so they started, you know, moving away from clinical care. So all of a sudden they found themself in this fiscal crisis.

Becky: Mm-hmm.

Michael: And there were estimates that 60 to 65% of the local health departments were not gonna have enough money to survive a few years down the line. So they're already thinking about how we're gonna ensure the survivability of our local health departments. That's what they were thinking about.

Becky: So then what happens during COVID in Kentucky?

Michael: Yeah, so essentially what happens is KADA, the local health department association says, let's figure out a strategy to try to get more money from the state. And they said to themselves, "You know what? There are certain things that we really are required to do as a local health department. We gotta give out birth and death certificates. We gotta do septic inspections. We gotta do restaurant inspections. We gotta run some wellness programs. We got... You know, there's a whole variety of tasks we have to do.

And so they said to themselves, how can we think about how many staff it actually would take to do the things we absolutely have to do to be a real-life functioning local health department? And how much money is that gonna cost?

Becky: Mm-hmm.

Michael: And so they started modeling that. And then they say, "All right. We can come up with these numbers, but to get the state to give us the money that the numbers say we need, we need help."

Becky: Right.

Michael: We're local health departments. We have good relationships with the state. We could start telling the state what we're doing and getting their input, but we need a coalition, and we need to have some influence in the state legislature. How do we do that?

Well, we need a couple of Republican champions for local public health and they found that. "We also need a real voice in the legislature." And so they hired an influential lobbying firm. I mean, you don't necessarily always think of local health departments hiring lobbyists, but they hired a lobbyist who they're still using today.

They also said, "We need support from county commissioners and local leaders, and we need support, if we can get it, from the health system.” So they built the coalition. They presented it to the state legislature. And they said, "You know what? The money that it's gonna take, is money that we want to come directly to the counties. The pitch we wanna make is that we're actually gonna be helping people in local counties."

And to be honest, the state department of public health was not so thrilled about this at first. Like I said earlier, local health department leaders had, and have, a pretty good relationship with the state. But this was a point of some friction at the time. Nonetheless, in late 2019, right after Andy Beshear became governor, the proposal was signed into law. And with that legislation came $37 million over the next 2 years in state general funds for local public health departments. Which is not bad for a small state like Kentucky.

And the legislation itself was really savvy. Number one, as I said, the money would go directly to the counties. But they also said, "You know what? We have to make sure the counties have some skin in the game here." So we're gonna say that every county is required to participate in this program." It's gonna be mandatory, not optional. But every county is gonna have to devote at least 1.8% of their property tax revenue to help supplement the, you know, the funding for this program.

Now, that's really interesting 'cause what that means, take Louisville, Kentucky, biggest county in the state. 1.8% of Louisville's property tax revenue covers more than the cost of the formula that said how much does Louisville needs to sort of run a public health department. So Louisville gets no money under this program. They get no money. Now, Louisville ended up supporting, you know, this legislation even though they get no money for it, which just really says something about the culture of the state.

Another thing they did that was really interesting, they actually put the funding formula into the legislation itself, so that it's not like an annual appropriation per se. There's a funding formula that sort of says, "This is how we're gonna make this work."

They also said in order to get the money, and this is the part that I'm especially interested in, in, order to get the money, you have to do a needs assessment of your community. And you have to come up with some public health issues in your community that you think are the most important issues on the agenda for your community.

It could be mental health. It could be vaping among middle school kids. It could be, you know, suicide rates. Could be gun violence. And you have to develop a, in effect, a separate coalition that is actually the public health agency working with the health system, working with the social services system, working with advocates to address that issue, and you gotta spend some of that money on that issue. So there's all these components, baking it into the legislation, the 1.8% rule.

Becky: Right. Skin in the game.

Michael: Skin in the game.

Becky: And accountability.

Michael: Mandatory accountability.

Becky: Yeah.

Michael: Keep the coalition going, and focus on the needs of your local community.

Becky: And talk a little bit about why that's important.

Michael: It's important because people need to feel that the tax dollars that they pay are providing actual, real return services to them. You pay tax dollars for your fire department. You pay tax dollars for your public library. You pay tax dollars for your police department. You feel like you're getting services for those.

I think at times, people feel, particularly during a pandemic and otherwise, that they're paying tax dollars, but the money's going to help somebody else. And in this case, I think people feeling like they're getting a direct benefit makes a difference.

I will say, it's not as if there's no issues or that money is always... Even baking it in. Uh, I'll tell you something I've learned relatively recently, for example. In the most recent round of sort of legislative activity that took place in April and early May of 2026, for the first time, they didn't get the full inflation bump that the legislation says they're entitled to, so they were a little disappointed about that. It's the first sort of tweak, you know, in, in this. They still get the formula, but as I said, there's this inflation bump they're supposed to get.

So again, even in Kentucky, which is a success story, it's a constant, constant battle to keep it going, and that's one of the lessons too. They haven't given up the battle. They've still got the lobbyist. They're not just relying on the state health officer. They're still got their coalition. They're there every day. They're trying to show the wins. They're trying to show we're making a difference. They're trying to show that there's return on investment, which is really, really hard in this situation. And so I think one of the things that happened is there's a bit of pride that they have, you know, in this, but that pride has to be renewed every day.

Becky: So they're strong at the local level, but they're also strong collectively.

Michael: And that's critical.

Becky: And I wanna, I wanna come back to your comment about the success story piece of it, but one of the things Professor Brown always used to say to me is, "If it's, if it's so great, why isn't everyone doing it?" So why, why won't this... It... Should this work everywhere? Like, why, why did it work in Kentucky?

Michael: It's a great question, and, uh, I think the fact that they had a very strong local health department association helped, but there are other states that have strong local health departments where it hasn't worked. I think the fact that they've got this culture of collaboration helped, but other states might have a similar culture of collaboration where it doesn't work as well. I think it helped that they felt they were in a real crisis early on, I think crisis sometimes produces a window of opportunity.

Becky: Mm-hmm.

Michael: Now, a crisis can produce a window of opportunity. But you still have to walk through that window of opportunity. They were able to take the crisis, walk through the window of opportunity with the coalition, and get this thing in place. Other states with a similar kind of crisis may not have been able to go through the window of opportunity in the same way, or they may not have faced the same crisis.

Becky: Yeah. Interesting. And now just, you called it a success story. Why?

Michael: Because I think it's, number one, enabled these local public health departments to do interesting and innovative work that I think is helping the people of their community. I think it's a success story because it shows a path through which other states can follow, even if they haven't yet.

Now, I will say, even with the money that Kentucky gives to local health departments, is it enough money for them to really do all they wanna do? Absolutely not. Is it as much money as New York State gives its local health departments? Absolutely not. So relatively and comparatively, it's helped.

Does it really position them to be the kind of public health champions in their community and really provide all the services that they think their community needs, really create all the relationships that they need to create, really solve all the problems? It's not perfect, uh, but it's a start.

Becky: Now let's talk about Indiana. Like, how is Indiana different?

Michael: Indiana is a fundamentally different kind of state than Kentucky when it comes to public health. And interesting, Indiana is a relatively wealthy state.

Becky: Mm-hmm.

Michael: I mean, it's got some big companies there, big Fortune 500 companies there. It has a a massive academic health system. It's got the sports capital of the United States. You can't have an NCAA tournament, you know, without, you know, um, without sort of it taking place in Indianapolis these days practically. I mean, it's a massive sports capital, so it has some money.

At the same time, Indiana ranked, going into COVID, 48th among the 50 states in the United States in how much the state actually provided local counties funding. And its metrics on obesity, on tobacco smoking, et cetera, were also in the 40s.

So you had this kind of situation where, you know, a relatively wealthy state not paying a lot of attention to their 90, 92, whatever it is, local health departments, which meant that local health departments were essentially raising funds themselves without much state funding to support their public health activities, along with whatever they got from the federal government and, and other kinds of things

Then COVID hits. And a couple of things start to happen. Number one, the tension between the counties and the states exacerbates. You mentioned organizational structure. Indiana is a classic home rule state when it comes to public health, What that means is the counties got to decide what they want to do with very little interference from the states. And it meant also that, as it turned out, there was a lot of tension and conflict between counties and the state over how COVID was gonna be handled.

Number two, disparities clearly emerge. Wealthier counties are able to much more effectively deal with COVID than lower cost counties. Number three, you had a governor, uh, named Eric Holcomb, republican governor, Republican state who was term-limited. He knew, you know, this was the end for him. He wasn't running for re-election again. He also became aware of these disparities. He hadn't really focused on public health before, but now he becomes aware of these disparities.

He also starts to, in effect, think to himself, One of our goals is to draw business into the state of Indiana. If we're ranking 45th or whatever it is in obesity and tobacco smoking, you know, are people gonna really wanna come to Indiana? You know, and I wanna draw business to Indiana." So there were lots of reasons he starts thinking about this.

Becky: Right. I wanna have a healthy workforce.

Michael: I wanna have a healthy workforce. I don't want big disparities. And you know what? I'm gonna set up a structure that's 180 degrees different from what happened in Kentucky. I'm gonna create a statewide commission to investigate maybe what we should be doing here."

But I have to be savvy about who I appoint to lead this commission. And he says, You know what? One person I want to lead the commission is a woman named Judy Monroe, who had been the health commissioner of Indiana, highly respected, and was now the CEO, president and CEO of the CDC Foundation, but still had a, a really good reputation in Indiana.

The other co-commissioner, though, uh, he says, "you know, there's a, a recently, very recently retired conservative Republican legislator named Luke Kenley, who basically ran the budget committee there. Highly respected guy, knows the finances, knows the money." I got to convince Luke Kenley that this is a good idea, because if I can get Luke Kenley, and he helps leads this project, he could do the inside game with a lot of his…

Becky: Okay, so this is where the politics come in?

Michael: This is where politics come in. He's very savvy about who he chooses. And he does have a health commissioner named Chris Box, who during COVID had been sort of the voice of the Indiana response, and actually was highly respected. So he says, "I've gonna have these two commissioners, plus Chris Box can work with them. and then we're gonna put on this commission some county health officials, some health system people, some advocates. We're gonna try to, in effect, create a coalition that didn't exist naturally."

Becky: So they have the right people, but what, what were they supposed to do? What were they told to do? They

Michael: They each had different tasks. Okay. Again, it's all politics in a certain sense. Number one, they start holding hearings around the state, the commission. You know, they go around the state, and they start saying to people, "What's working, what's not working. They really want to have this commission understand what's happening.

Michael: Meanwhile, Kenley's also starting to work the inside game a little bit. And they realize pretty early on that while they've got a top-down strategy, number one, they need the coalition. They need everybody on board, and they get the health systems agree to join. The business community, Chamber of Commerce, and others agree to join. Not only the commission, but the effort to increase state funding.

And that coalition basically says to itself, “How do we get from coalition to legislative action?" And what they realize is they have to convince local county leaders, the city council people, the county commissioners, the mayors, you know, the home rule people, that increased funding for local health departments in the state is a top priority for Indiana. And unlike in Kentucky, they decide that this new program will be optional for counties to join.

And the money, as in Kentucky, is gonna bypass the state. It's gonna go directly to the counties, and the counties are gonna think about what is a need in their community to use some of the money.

Probably the single most pivotal thing was they got the endorsement from the associations, from the county commissioners, the city council, and the mayors, that this was a good, a good piece of legislation. In year one, I believe 86 of the 92 opted in. Year two, everybody opted in, so they had support

Becky: So they had 100% support without a mandate,

Michael: Without a mandate, by year two.

Becky: Interesting. But I wanna go back to building the coalition for a minute. What were the incentives for all these people to join or to be a part of it? Do they talk about that?

Michael: I mean, I think the legislation itself, uh, let me just illustrate how much money they put in. Indiana has a budget that comes out every two years, so a biennium budget. For the last X years prior to this, Indiana had been allocating or appropriating $7 million a year to local health departments

Becky: Okay. This is pre-COVID?

Michael: This is pre-COVID. Right.

Becky: Okay.

Michael: 14 million over two years. The legislation that they enacted, this Health First legislation they enacted, $225 million.

Becky: Over two years.

Michael: Over two years. So they went from 14 million to 225 million. Now again, did that put them in-New York or Massachusetts levels? Maybe not. But talk about a dramatic increase.

Becky: I mean, just the, you know, attention to the fact that they're making that kind of financial investment says something.

Michael: Yeah. I mean, huge. Yeah. Huge. it's complicated, but I think the fact that there was a realization that Indiana ranked 48th in the country, uh, in what they, in, you know, in, in the funds that they gave, uh- yeah and I think while there was o- there definitely was opposition. There some opposition, it was not, you know, unanimous. Yeah. I think there was a feeling we can do better. We should do better. You know, ...we shouldn't be 48th in the country in, in how we're supporting our local health departments.

Becky: Yeah.

Michael: We do wanna draw a healthy workforce. We don't want the kind of disparities we have. There was a moment where I think, you know, they were able to say, "We in Indiana, in a crisis like this, should be able to do something for our, for our people.

Becky: Yeah. Um- they had a real shared goal even if they had different ways of going about it, and this felt like an opportunity to- It felt like an opportunity.

Michael: I mean, I think, you know, for each of the members of the coalition, there was really no downside to this.

Becky: Yeah.

Michael: You know, it's not as if was being taken away from hospitals.It's not as if money was, being taken away from, the business community. The chamber of commerce in a community could say, you know, "This could help our community." So again, I think the fact – localism, you know, the fact that they were able to sort of " say, We want to have money to support these core foundational public health activities, plus some extra things," it resonated. Um- Yeah ... and it's a bit of...I said, uh, we were talking a few minutes ago, there's a crisis and then there's a window of opportunity?

Becky: Yeah.

Michael: In Kentucky, there was a crisis and they went through that window of opportunity. The crisis in Indiana. Was the pandemic and what it was revealing about their public health system. And I think the coalition came up with a strategy that let them also walk through that window of opportunity. 'cause now they've got this vast infusion of money, and they have a lot of discretion as to how they're gonna spend it.

Um, and I think, you know, there were fundamentally different ways that counties spent the money. Indianapolis, for example, Marion County, Indianapolis, spent about half of its first-year allocation raising salaries for public health nurses and other staff because their salaries were so low compared to even nearby states, they were constantly losing not only to nearby states, but to the local hospital or wherever, just for retention, that was... the other half of the money, they said, "We're gonna come up with partnerships with social services groups. We're gonna hire community health workers," et cetera, et cetera.

Another county, that I really think was an interesting and impressive county said, "All right, we've identified in our community, uh, a sort of a top priority being dramatically increased vaping use among middle school kids. So what we're gonna do is come up with a, a major anti-vaping program in our community gonna target every middle school kid, whether they're in a public school or private school, whatever and that's what we're gonna do." So there were a lot of differences. But I think there were some really interesting programs that came out of it.

Becky: And they, in many ways, it sounds like they stayed true to their model. Like, we're gonna be hyper local. And the things that we see as issues in our local area, we're gonna address.

Michael: Along with supporting the basic infrastructure. Making sure that we've got people to do the restaurant inspections, et cetera, et cetera.

Becky: Right. Well, right. Which is a- Yeah ... a g- part of their core, core mission. Um, So then you go back to Indiana.

Michael: Um, well, actually, you might remember this. So then we get to, when was it?

Becky: Yes, April- April-of '25 '

Michael: 25 ...of '25. And we're having an event here at Columbia.

Becky: That's right.

Michael: And one of the people that we invited to the event was the health commissioner of Marion county, Indianapolis, woman named Virginia Cane. Longtime public health leader, longtime leader of, of Marion County's health Department. Just a wonderful, wonderful woman. So we had invited her to participate in this panel.

Becky: Yeah.

Michael: She arrives at the airport, gets in an Uber, and has a phone call while she's in the Uber, and she arrives at our dinner, uh, and she says, I can't believe it." She says, I just found out that the legislature cut the funding by about 70% for the next biennium, the next two years. We thought there might be some cuts. You know, we thought instead of 225 million, it'd be 200 or 190, you know. 'Cause there were these issues that had come up, which we could talk about.

We never expected it to go down from 225 to 80 statewide." Now, it didn't go back to 14. But it went from 225... And she said, "In my county, that means I'm going from $20 million, which is my appropriation, to a little over one million."

Becky: Wow.

Michael: And she was like, she was in shock. Part of the problem was she wasn't in the room when this was all happening, which we can talk about.

Becky: Right. So what happened?

Michael: Well, first of all, I think one thing that happened is during that first two years, the opponents started harping on things that maybe they hadn't had a chance to harp on 'cause it, you know, when the coalition was so strong. so some people were starting to say, " Oh, you know, they're using some of this money for undocumented immigrants," you know, and, and that the immigration thing has become, you know, a major political issue. Others were saying, this program's been in place for a year now. What's changed?" You know, have

Becky: ROI.

Michael: You know, what's the return on investment? I don't see any ROI. Other people were saying, "Oh, you know, I went to the county fair, and at the county fair there was a booth, and at the booth they were handing out brochures. Am I paying for bro- you know, what good is handing out brochures?" So there was this opposition that was starting to brew.

Meanwhile, the coalition, and this is probably the most important thing, the coalition had dispersed. Judy Monroe goes back to Atlanta. She has a full-time job as the president and CEO of the CDC Foundation, so she's basically focusing on that. Luke Kenley, he was a retired senator at this point, state senator. He goes off. Chris Box, who was the state health officer, retires. Actually, she retired even before the end of the session, you know, and Governor Holcomb had appointed another health officer.

But now there's a new governor. There's a new governor. Governor Braun, who, you know, doesn't have the same kind of commitment that Governor Holcomb had to all this. Now the new governor's, one of his number one priorities is cost containment, and so he's going after full-blown right now the big academic and medical system in Indiana. So they're occupied with fighting Braun's–

Becky: Their own issues.

Michael: The county officials are worried about rising property taxes now. Um, so they're, like, worried about that. The advocates are worried about Medicaid primarily, and Medicaid work requirements and what's happening. You know, I mean, they've got this public health money, but there's this tsunami of Medicaid cuts coming.

Becky: Right. Pandemic's not as visible.

Michael: Pandemic's not as visible. Complaints are in the air. And then three days before the final day of the session, the budget committee at the legislature issues a report saying the state's gonna have a massive deficit, and we gotta make cuts. Turns out they overstated the deficit. It wasn't quite as bad as they were saying it was gonna be, but all of a sudden there's panic.

Becky: Mm-hmm.

Michael: And now where are they gonna cut?

Becky: Mm-hmm.

Michael: Now, there's no coalition at this point. Uh, in fact, one, there's no clear showing of return on investment.

Becky: Right, I was just gonna say the immediacy of–

Michael: There’s also – one of the things that had happened was the Fairbanks School of Public Health had been contracted to do an evaluation of the program, which they had just begun. But the new governor cuts off the funding for that, so there's no evaluation

Becky: So no one knows actually-

Michael: Because there’s this battle between the governor and the state university system going on over control of the university system. So now there's three days to go. There's no coalition, and the only one in the room, you know, what's the play Hamilton? You know, who, who, who's in the room, you know, when it happens, is the state health officer for the new governor.

Becky: Right.

Michael: You know, she can't exactly go in there and sort of be fighting what the new governor wants to do.

Becky: Right.

Michael: So exactly what happens in that room is unclear. She emerges from the room saying, in effect, I did the best I could, and I got us 80 million, and that's better than 14." So Now, you've got counties in Indiana saying, "I knew we couldn't trust the state. I knew they were gonna pull the rug on " this. I knew we'd start these programs, and the next thing you know, there'd be no money, and our relationships with our partners, you know, we've got these contracts we've entered into. What are we gonna do?"

Becky: And the community

Michael: And the community. It's like there's this feeling like the rug has gotten pulled out of the public health community. I mean, public health is often the first place that gets looked at politically, you know, to cut because unless you've got that organized coalition, unless you've been able to show you're spending money, unless you've showed some win, you know, it's just hard.

Becky: Yeah. And so what happened to all the programs? What happened to the workforce who had just received salary increases? Were they laid off?

Michael: They can't cut the salaries. I mean, that's happening now. I mean, this is like, now. Basically the cuts, you know, that were implemented in '25 are sort of for '26, '27. You know, so quite honestly, what's happening now, it's a little murky, you know? I mean, there's a lot of effort to sort of figure out how to adjust to a very changed environment.

There's beginning of talk about, maybe we should try to resurrect the coalition. Maybe we should try to do this. Maybe we should try to do that. Can we convince Governor Braun that this is really should be a high priority? Can we think about how to create the coalition? So again, I think this is a live story right now. Uh, and this actually reflects back to my... You asked me at the very beginning about my research and how I conduct research.

Becky: Yeah.

Michael: It's often important for me, anyway, if I can, you can't always do it, but if I can, to keep track of things longitudinally. If all you did today was read the article that we wrote in The Milbank Quarterly, you would say to yourself, "Boy, Indiana, model, great. Good story. Let me assign this to my class. Let me read this," whatever. You wouldn't know about what's happening now. These stories keep evolving. They keep changing. And that, I think, is one of the lessons. You know, we could talk about lessons, but one of the lessons is the politics never ends, and the story never ends,

Becky: I wanna just now maybe take three steps back and look big picture. What were some of the similarities between Indiana and Kentucky?

Michael: Well, one is definitely the need to show local communities that there's a win for them and people feel like they're getting a, a win out of it. I think another is the need for coalitions. Um, Kentucky had and has kept its coalition. Indiana had, but then it dispersed. I mean, I think Indiana's coalition celebrated its victory, but it didn't necessarily recognize that the coalition had to stay together in order to keep fighting the fight.

I would sort of say in a certain sense, politics, politics, politics. You know? And sort of having a political strategy not only to get, funding, but to figure out how to use the funding to figure out how to demonstrate you're showing a return on investment, as hard as that may be.

Becky: Yeah

Michael: And to figure out how to keep in the legislators' ears, you know, the fact that this is important.

Becky: And in some ways, how do you balance the needs of your local community, right, to a core, the value of that local component, with the sort of opportunities that come from doing all things together, this coalition piece, right? And that it's really that balance back and forth- ... um, that Kentucky seems to have figured out.

Michael: it's like saying, "We'll go without money." Right. I mean, that's kinda magical in a sense. You know? Yeah. Um, it's like if New York City said, "We're gonna work on a program with New York State where we understand all the money's gonna go upstate and not to the city." Right. That could happen. I'm not saying it doesn't ever happen. But it, it's, it's not easy.

Becky: Yeah. What do these stories collectively, you know, or, or individually tell you about, you know, how public health funding actually works in the US?

Michael: You know, I think one thing it tells you is bake the formula into the legislation. You know, if you have to go back every two years for an appropriation and the political dynamics are, are changing and there's new governors and coalitions, et cetera, there's no guarantee by baking it into the statute. Statutes can be overturned. Andy Beshear is off running for president right now. He's not gonna be governor. Who knows what's gonna happen- Right ... a year or two from now? But if you, if you've got a formula in legislation, it's much tougher to actually repeal legislation- Right ... than to cut

Becky: Right. So kind of put in the work upfront to pass it through a legislation,

Michael: And you need legislative champions. Yeah. And those legislative champions have to stick with you. And I think you need lobbyists. You need, you need to be in the game. Yeah. You need to be in the room.

Becky: Yeah. And so maybe just talk a little bit about how much is policy and how much is politics.

Michael: Yeah. I mean, there's a ongoing debate in political science about whether policy shapes politics or politics shapes policy. I'm firmly of the belief that policy shapes politics. Any policy proposal has its own set of winners and losers and political dynamics, and so the policy proposal, I think, shapes the political environment. That's not to say that it's not a feedback loop. Obviously, the political environment has an influence on what's doable and what can work and what cannot work. But sort of as a core guiding principle, I think policy shapes politics.

And so in, in this situation, the policy that both Indiana and Kentucky were proposing, trying to get more funding, trying to help their local departments shaped the political strategy that they came up with to get that funding.

I think another thing that's just really important to know is, uh, I've just been reading about how the federal government has, like, this, the biggest budget deficit it's ever had in, in, like, world history or in American history, and what is that gonna mean? States don't have that luxury. You know? Indiana and Kentucky have to balance the books. I mean, there's budget tricks they can come up with to try to .get out of some jams that they're in.

But basically, they gotta balance the books, which means you really gotta, you know, you gotta pay attention to numbers. You gotta, pay attention to sort of the, the financial details, and You have to be able to present that in a way that shows you've got some savviness about numbers. So I think what Kentucky was able to do with coming up with these models was say, "You know what, we're not looking for New York City-style funding."

Becky: Right.

Michael: What we're looking for is we wanna have a local health department that can have the staff needed and get the pay they deserve to help our community. And here's what it takes to do that. We've actually crunched the numbers, you know. And so we're giving you real-life numbers. So we're not just saying... Like for example, in Indiana, as much as I like and respect Indiana in the process, were they gonna get 200 million or were they gonna get 300 million? Were they gonna get 80 or were they gonna get 120? There's sort of a looseness about the number. That number is not necessarily tied to the story or to the, the outcome. Kentucky has clearly tied the dollar request to the services they wanna provide.

Becky: To exactly what they needed and why. So they told their story.

Michael: Yeah. They've told their story in a very effective way.

Becky: All right, so where... What, what's next? Where do we go from here?

Michael: So where we go from here for myself is I'm just right now in the midst of visiting each of these five states again. And over the next several months, you'll hear me sort of saying what's happening in these states and, and what I think the lessons are from round two.

Becky: You gonna write something?

Michael: I'm gonna write something on this, yeah.

Becky: Okay, so stay tuned.

Michael: Stay tuned.

Thanks again to Rebecca Sale for joining me on our final episode of Who the Health Cares Season 2.

Our team is already hard at work on next season of the show. In the meantime, keep an eye on this feed for some bonus content we’ll be releasing over the summer.

We also want to hear from you! If you have a question about the history, politics or substance of our public health system, email us at cphspodcast@gmail.com and we may answer it in a future episode.

Till then, this is Michael Sparer, signing off from the Center for Public Health Systems, at Columbia University.

This episode was produced by Grace Rubin.

Our sound engineer is Zoe Denckla.

Alex Weaver is our social producer. He also composed our theme music.

Fact-checking by Monica Stanovic.

Rachel Ferat is the Program Manager for the Center for Public Health Systems

And Rebecca Sale is the Head of Strategy and Partnerships for the Center for Public Health Systems.

Thanks to all of you!

Resources:

Politics and the Public Health Workforce: Lessons Suggested from a Five-State Study | Milbank Quarterly

Two red states show how the nation’s public health system can be fixed - The Boston Globe

National Profile of Local Health Departments