Strengthening the Public Health Workforce: Streamlining Government Processes and Dedicated Sustainable Funding
December 10, 2023
Introduction
Following years of unprecedented challenges to the public health and healthcare workforces—including pandemic-related workplace violence, job-related stress, and burnout—policymakers across the nation are taking action to recruit and retain workers crucial to meeting the foundational public health services in their community. A 2021 study estimates that health departments needed to hire 80,000 additional staff to provide these foundational public health services. A sample of state and local government public health agencies revealed a loss of nearly half of all employees between 2017 and 2021, a figure that rises to approximately 75% of employees under age 35 and those with less than five years at the agency. Reasons given for leaving include low pay, limited career advancement opportunities, work overload, and burnout. If the current attrition rate of public health professionals continues, state health agencies nationwide could lose more than half of the current workforce, draining these agencies of critical institutional knowledge and experience.
Similarly, the healthcare workforce continues to face significant challenges, with national shortages projected for primary care providers, physicians, nurses, and behavioral health professionals. A recent study assessing the U.S. nursing workforce noted significant rates of nurses indicating that they plan to leave the profession while simultaneously having a limited talent pipeline, calling on policymakers to develop solutions to foster a more sustainable and safe working environment.
Legislative Trends
Sustainable Public Health Funding
Most state and territorial health agencies depend on federal funding to provide core public health services such as infectious disease control and chronic disease prevention. ASTHO continues to advocate for sustainable and flexible federal public health funding and at the same time several states are taking action to invest state resources in their public health system. In 2023, Maine enacted LD 1722, creating a Blue Ribbon Commission to develop a plan for sustained public health investment. Maryland enacted HB 214, refocusing its Public Health Commission on assessing local health departments’ foundational public health capabilities and requiring the commission to hold public meetings in different areas of the state to inform recommendations submitted to the governor.
Policymakers in Indiana enacted SB 4, the culmination of nearly two years of work across the state to transform its public health system. Building on the work of the 2021 Governor’s Public Health Commission, the new law establishes core public health services for the state and provides local governments the option to receive additional state funding, 60% of which must be spent on preventive core services. As of October 2023, almost every county opted to receive the additional funding, and 96% of the state is receiving the enhanced core services delivery.
Informed by the work of Indiana Governor’s Public Health Commission, Indiana enacted SB 4 which reimagines the relationship between the state and local health departments, accompanied with flexible funding for local governments to achieve core public health services in a manner best suited for their jurisdiction.
Supporting Public Health Workforce
Despite an increase in public health graduates, as few as 17% of public health graduates obtain jobs in governmental public health after graduation. With public health graduates citing significant challenges in navigating state government hiring processes, efforts to reform governmental hiring processes could improve employee recruitment. At least three states—Connecticut (CT SB 984), Illinois (IL SB 2228), and Nevada (NV SB 431)—enacted legislation this session to streamline government administration, including public employee recruitment and retention. Connecticut’s new law streamlines the process of appointing qualified and suitable candidates to fill positions in a way that maintains “efficiency and productivity.” Illinois revised its personnel codes, clarifying ways staff can be promoted internally and expanding the ways potential employees can be assessed to determine whether they meet the minimum qualifications. Nevada’s new law requires the state’s administrator of human resource management to develop a master classification plan for state employees and for the state personnel commission to promulgate rules for recruiting and evaluating job applicants.
Along with streamlining administrative processes, at least 33 states proposed pay increases for public employees in fiscal year 2024. For example, New Hampshire’s new law (NH SB 74) provides additional flexibilities to hire new workers at a higher rate and adjust pay to retain existing workers. Idaho (ID H 251) and Montana (MT HB 13) both enacted across the board pay increases for public sector employees. Additionally, Oklahoma (OK SB 16) will now provide paid maternity leave to all employees who have been employed full-time by the state for at least two years.
Supporting Healthcare Workforce
Ensuring that the healthcare workforce meets the needs of their communities can improve public health. With significant shortages across a range of professions, policymakers are investing in incentive programs, such as student loan repayment programs, and taking steps to strengthen the workforce pipeline.
In 2023 at least six states—Colorado (CO HB 23-1246), Kentucky (KY HB 200), Louisiana (LA SB 20), Missouri (MO HB 402), Oregon (OR SB 490), and Tennessee (TN HB 1312)—enacted laws supporting training and education for future healthcare workers. Kentucky’s new law directs its council on postsecondary education to administer a newly formed healthcare workforce investment fund to provide training scholarships to increase the diversity of the workforce and meet specific needs of historically underserved populations. Colorado appropriated funds to support the development of a short-term nursing credential at community or technical colleges in the state. Louisiana’s new law expanded a scholarship program to include “allied health” professions (e.g., respiratory therapists and medical technicians).
Missouri’s law established a health professional loan repayment program, providing forgivable loans for the purpose of repaying healthcare, mental health, and public health professionals’ existing loans for educational expenses. Oregon’s law directs funds the Oregon Health and Science University to support additional medical residents specializing in family medicine, maternal healthcare, and reproductive healthcare. Tennessee’s new law provides a pathway for physicians licensed in other countries to be hired by a U.S. hospital without completing a U.S.-based medical residency.
Looking Ahead
During the 2024 state legislative sessions, ASTHO expects state legislatures to continue working to support the public health and healthcare workforces by:
- Considering state funding to sustain previous federal investments in public health workers.
- Modifying professional licensing requirements to retain and expand the public health workforce.
- Streamlining state hiring processes and modernizing employment policies.
Investing in workforce pathway and pipeline programs, particularly ones to support underserved and under-resourced communities. - Considering using artificial intelligence in public agencies, including to establish protections against bias in hiring decisions.
In 2023, Rhode Island Department of Health worked with policymakers to raise the number of full-time equivalent staff available to the agency.