Politics and the Public Health Workforce: Lessons Suggested from a Five-State Study.

Policy Points The United States public health system relies on an inadequate and inefficient mix of federal, state, and local funding. Various state-based initiatives suggest that a promising path to bipartisan support for increased public health funding is to gain the support of local elected officials by providing state (and federal) funding directly to local health departments, albeit with performance strings attached. Even with more funding, we will not solve the nation's public health workforce crisis until we make public health a more attractive career path with fewer bureaucratic barriers to entry. CONTEXT: The COVID-19 pandemic exposed the shortcomings of the United States public health system. High on the list is a public health workforce that is understaffed, underpaid, and undervalued. To rebuild that workforce, the American Rescue Plan (ARP) appropriated $7.66 billion to help create 100,000 new public health jobs. As part of this initiative, the Centers for Disease Control and Prevention (CDC) distributed roughly $2 billion to state, local, tribal, and territorial health agencies for use between July 1, 2021, and June 30, 2023. At the same time, several states have enacted (or are considering enacting) initiatives to increase state funding for their local health departments with the goal of ensuring that these departments can deliver a core set of services to all residents. The differences in approach between this first round of ARP funding and theseparate state initiatives offer an opportunity to compare, contrast, and suggest lessons learned. METHODS: After interviewing leaders at the CDC and other experts on the nation's public health workforce, we visited five states (Kentucky, Indiana, Mississippi, New York, and Washington) to examine, by means of interviews and documents, the implementation and impact of both the ARP workforce funds as well as the state-based initiatives. FINDINGS: Three themes emerged. First, states are not spending the CDC workforce funding in a timely fashion; although the specifics vary, there are several organizational, political, and bureaucratic obstacles. Second, the state-based initiatives follow different political paths but rely on the same overarching strategy: gain the support of local elected officials by providing funding directly to local health departments, albeit with performance strings attached. These state initiatives offer their federal counterparts a political roadmap toward a more robust model of public health funding. Third, even with increased funding, we will not meet the nation's public health workforce challenges until we make public health a more attractive career path (with higher pay, improved working conditions, and more training and promotion opportunities) with fewer bureaucratic barriers to entry (most importantly, with less reliance on outdated civil service rules). CONCLUSION: The politics of public health requires a closer look at the role played by county commissioners, mayors, and other local elected officials. We need a political strategy to persuade these officials that their constituents will benefit from a better public health system.

Getting The Price Right: How Some Countries Control Spending In A Fee-For-Service System.

Although the US has the highest health care prices in the world, the specific mechanisms commonly used by other countries to set and update prices are often overlooked, with a tendency to favor strategies such as reducing the use of fee-for-service reimbursement. Comparing policies in three high-income countries (France, Germany, and Japan), we describe how payers and physicians engage in structured fee negotiations and standardize prices in systems where fee-for-service is the main model of outpatient physician reimbursement. The parties involved, the frequency of fee schedule updates, and the scope of the negotiations vary, but all three countries attempt to balance the interests of payers with those of physician associations. Instead of looking for policy importation, this analysis demonstrates the benefits of structuring negotiations and standardizing fee-for-service payments independent of any specific reform proposal, such as single-payer reform and public insurance buy-ins.

Trump v. The ACA.

Before his incoherent response to the COVID-19 pandemic, the focus of President Trump's health policy agenda was the elimination of the Patient Protection and Affordable Care Act (ACA), which he has called a 'disaster'. The attacks on the ACA included proposals to repeal the law through the legislative process, to erode it through a series of executive actions, and to ask the courts to declare it unconstitutional. Despite these ongoing challenges, the ACA remains largely intact as the U.S. heads into the 2020 election. The longer term fate of the law, however, is uncertain and the outcome of the 2020 election is likely to have a dramatic effect on the direction of health policy in the U.S.