Indiana underfunds public health despite collecting the revenue to properly invest in it

I read the Public Health Commission report in its entirety so you don’t have to

December 15, 2022 7:00 am
public health

In August 2021, Indiana Gov. Eric Holcomb issued Executive Order 21–21, which convened a commission to provide counsel on the state of public health in Indiana. The most striking finding ultimately is the extent to which Indiana has neglected investing in the health of its citizens.

The Commission issued its report about a year later. There were multiple “holy cow” moments for me as I read it. I will summarize the larger findings and contextualize the recommendations for this coming legislative session.

The backdrop for the Commission’s work is a falling life expectancy for Hoosiers and a significant rise in death rates in the younger age groups. You can read a terrific piece by Matt Kinghorn in the Indiana Business Review about the details of our declining life expectancy. But obviously a falling life expectancy is a major red flag in public health.

The Commission report is detailed and amazingly well researched. It includes recommendations in six subject matter areas. I will not talk about all of them here, but will focus on the “low hanging fruit”— starting with overall funding of public health.

In 2018–2019, the last year before the pandemic, the average state in the U.S. spent $91 per citizen on public health funding. Indiana spent $55. We invest only 60% of what the AVERAGE STATE did in 2019 on public health. And the amount we have spent per capita has been cut in half (in 2022 dollars) since 2004. We spend a small amount and have been shrinking that amount greatly over time.

But this only tells part of the story. Most Indiana public health spending does not come from it’s own coffers — it comes from public health grants from the Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC). If we look at the amount of money spent per capita on public health from Indiana coffers, we only spend $15 per Hoosier on public health. The rest of the $55 quoted in the report (73%) comes from CDC and HRSA grants.

In other words, only 27% of Hoosier public health funding comes from the Statehouse. The rest comes in the form of federal grants. The national average of total public health spending that comes from state coffers is 38%.

Cyclical effect

Low state coffer public health spending compounds itself. Federal public health grant funding is directly related to the amount of state spending — the more a state spends on public health, the more federal dollars come to that state for public health interventions. Indiana ranks 40th among states for per capita HRSA funding and 50th among states for CDC funding.

Another way to put it: nationwide, every $1 in state public health funding brings in another $2.64 in federal public health money.

Why is this the case? Because public health entities have to pursue federal grants — they aren’t just given out automatically. If we are underfunding public health, we have no one to apply for grants and collect data to justify that grant funding. So we miss out on federal dollars because we don’t spend any state dollars to create the infrastructure to obtain federal support.

Last week was the annual “Labor of Love” conference, held annually since 2012 to focus on improving maternal and infant mortality. The results have not been good. Over the last 10 years, Indiana remains 42nd in infant mortality (death within a year of birth) and maternal mortality rates have only worsened over the past decade.

Indiana remains in the bottom 1/3 of states when it comes to overdose deaths.

We are 34th in the nation in firearm death rates.

We are 39th in the nation for COVID-19 death rates (in the last quarter). We are 41st in the country for number of residents fully vaccinated (57%, national average 68%).

We are 37th in the United States for teen birth rate.

These outcomes mean Indiana’s residents suffer more than needed. It also leads to significant downstream state health costs.

The pitch

The Governor’s Commission report suggests that Indiana should consider investing an additional $246 million of state funding per year in public health funding, which would bring the state up to median 2019 per capita spending in the United States.

There are reasonable arguments as to why this may not be a good way forward (all of which I disagree with). But one argument which holds very little water is one which suggests that we cannot afford it.

Indiana has had a budget surplus in all years but 2020 (the pandemic year) since 2010. The average budget surplus (including the deficit in 2020) during that time is $677 million dollars — far more than the $246 million that the Governor’s Commission has suggested would be appropriate.

This summer, given the fact that Indiana had a $6 billion surplus, Holcomb called a special session to ultimately give Hoosiers a $200rebate. This amounts to $1 billion, which means Indiana could have funded four years of the suggested increase in public health funding with these funds.

This year is a budget session – and the Indiana legislature should support the Governor’s Commission and fully fund public health. History tells us we can do this without a tax increase.

These issues are complicated issues without easy fixes. Public health policy is a messy combination of medicine, law, sociology, economics, and education.

Improving public health means accepting that everyone is not perfect and meeting them where they are. It means understanding the world as it is, not as it should be. It is important.

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Gabriel Bosslet
Gabriel Bosslet

Dr. Bosslet is Associate Professor of Clinical Medicine in the Department of Pulmonary, Critical Care, Sleep and Occupational Medicine at Indiana University and Fellowship Director for Pulmonary and Critical Care Medicine. He helped keep Hoosiers informed about the pandemic through the Hoosier COVID-19 Update Facebook page.