State Efforts to Bolster Funding for Core Public Health Services

October 25, 2024 | Maggie Davis

Decades of underfunding weakened the public health system’s ability to respond to the COVID-19 pandemic, revealing the fragility of a chronically under-resourced field tasked with responding to a global emergency. Despite influxes of public health funding to respond to the COVID-19 pandemic— including through the CARES Act and American Rescue Plan Act—and federal efforts to support longer-term improvements through the Public Health Infrastructure Grant, public health agencies are preparing for a potential reduction in funding after emergency funds expire and previously approved but unspent federal funding are reduced or cancelled.

In recent years, several states took significant steps to strengthen their public health infrastructure by increasing funding critical for improvements, defining the core services that health departments should provide, and establishing public health standards.

State Increases in Public Health Funding

At least three states increased funding for public health services in budgets adopted during the 2024 legislative session:

• In March 2024, Kentucky approved a $30 billion biennium state budget (HB 6) for FY25 and FY26, including a $1 million increase for supporting local health department staff.
• Michigan adopted SB 747 in July 2024, establishing a $81.3 billion FY25 budget, which included $37.6 billion for the Department of Health and Human Services (a $1.9 billion increase from FY24 appropriations of $35.7 billion), $4 million in new funding to support peer recovery coaches, and $9.1 million to support nursing loan repayment programs.

• Washington adopted a supplemental budget in March 2024 (SB 5950), which increased funding for behavioral health services and that builds on work started in 2018 that estimated an additional $225 million annually to support foundational public health services. In 2019, Washington enacted HB 1497, which defined foundational public health services that governmental public health must provide to each community and restructured the state public health funding.

  The new funding structure requires the state health department to consult federally recognized tribes and reach consensus on how to distribute the funding for foundational public health services. It also requires the state health agency to jointly certify with the Washington local health association and state board of health to the office of financial management that they agree on the distribution of funds. Additionally, state legislators substantially increased foundational public health services funding in the subsequent biennium budgets, growing public health investment from $12 million in FY17/FY18 to $324 million in FY23/FY24. This investment has increased the governmental public health system’s capacity and increased efforts to improve equity across the public health system.

Several states also passed budgets with targeted investments in certain aspects of the public health and healthcare system even though overall funding was reduced:

• Arizona’s FY25 budget cut 3.45% from most state agencies in an effort to close a budget deficit while also providing an additional $2 million to improve workforce capacity for licensing, inspection, and enforcement of healthcare facility regulations.
• Similarly, Missouri’s FY25 budget reduces state spending by 3.3% from FY24, with the budget also providing $3.5 million to help alleviate healthcare staffing shortages.
• Maryland’s FY25 budget (SB 360) decreased 1.8% from the FY24 working appropriation but allocated $21 million for 300 new positions across the department of health.

Additionally, in 2022, California enacted SB 184, which required the public health department to create a program supporting vital public health activities and services provided by local health departments. This program, known as the Future of Public Health Initiative, is intended to modernize the state’s public health system by infusing funds to supplement existing local funding for public health activities. Facing a state budget gap, an early budget proposal would have eliminated the $300 million initiative; however, the enacted budget maintained the majority of the Future of Public Health initiative’s funding.

Establishing Performance Standards for Local Public Health Departments

Along with increased state investment, several jurisdictions are working to ensure greater access and quality of core public health standards. ASTHO’s 2022 health agency profile survey identified 27 states with a decentralized/largely decentralized structure, meaning that most core public health services are provided by local health departments operated by local governments or regional public health districts. For decentralized public health systems, it is important that state public health leaders build strong relationships with local health departments, working collaboratively to improve the health of their communities. In recent years, several states have taken legislative and regulatory action to support those relationships and ensure that local health departments meet minimum standards for providing core public health services.

West Virginia, which has a decentralized public health system, enacted HB 4113 in 2022 to strengthen support for local health departments and establish minimum standards for the provision of local health services. The law required the state health department to create a Center for Local Public Health tasked with enhancing the quality and availability of essential public health services by providing technical assistance and establishing performance standards that are used to help allocate and distribute funding for the local boards of health. The department established basic public health service standards by legislative rule (Series 73 rules) in 2023, including standards for investigating and controlling disease, environmental health protections, and supporting access to immunizations.

Similarly, in 2023 the Massachusetts department of health announced new performance standards for local health departments aligned with a special commission’s Blueprint for Public Excellence report. These performance standards followed a 2020 law directing the state health department to create a program to improve the efficiency and effectiveness of local public health service delivery by creating certain standards and providing training and resources as funding allowed.

Continued Advocacy for Sustainable Public Health Funding

States continue exploring ways to bolster public health infrastructure through higher standards for core public health services and improve delivery by increasing state investment, while trying to mitigate upcoming reductions in federal funding. ASTHO will persist in its efforts to advocate for sustained, flexible funding for public health and monitor this important public health issue, providing relevant updates.