The Indiana General Assembly passed a bill this session, signed by Republican Gov. Eric Holcomb on Thursday, that has cash-strapped county health departments excited but some conservative county leaders leery.
The new law makes available $225 million over the next two years for county health departments to spend on a broader range of initiatives. State law now requires health departments to regulate eight health areas. They include inspecting food service establishments, septic systems, and public swimming pools, controlling the spread of communicable diseases, and maintaining birth and death records.
Under the new law, counties that choose to opt into the new system must also tackle 15 new types of public health problems. They range from smoking and teen vaping, reviewing suicides, overdoses and child fatalities, and preventing and reducing chronic illnesses that include obesity, diabetes, heart disease, and cancer.
Counties would have to spend at least 60 percent of the new money on the new initiatives, and no more than 40% of it on the existing services.
The bill stems from two years of work by the Governors Public Health Commission. Holcomb convened the commission because Indiana ranks 45th in public health funding, 45th in smoking and tobacco use, 46th in obesity, 43rd in mental health and 41st in childhood immunizations.
The law gives counties a base amount of $26 per resident annually, plus more money depending on a county’s social vulnerability index and average life expectancy.
For some perspective, this year St. Joseph County received about $1 million from the state. Under the new law, the county would receive at least $7 million a year, and likely as much as $10 million.
Robin Vida, with the St. Joseph County Health Department, said the new law is the best thing she’s seen happen to public health in her 16 years in the field.
“This is a huge, huge win for public health here in the state of Indiana,” Vida said. “Our state has just always been at the bottom for public health funding per capita and I think it shows. We know that there are lots of instances where we have to be reactive to situations rather than being proactive because the resources just haven’t been there to allow us to be more preventative.”
But Republican members of the St. Joseph County council and commissioners have said they’re leery of accepting the money because they fear it will mean losing local control of public health. Some, like County Council Member Amy Drake, think the health department overreached during the pandemic when it mandated face masks.
While lawmakers were debating Senate Bill 4, Drake traveled to Indianapolis and testified against it before the Senate Health Committee. She brought with her a letter signed by all five St. Joseph County Council Republicans, who enjoy a majority over four Democrats on the council, and all three county commissioners, all of whom are Republican. Six Marshall County Council members, all Republicans, also signed the letter.
St. Joseph County Council Member Dan Schaetzle was one of the people who signed it.
“If we opt into it, we want to be able to effect definable metrics,” Schaetzle said. “So what is a definable metric? That would be like infant mortality rates. I am not interested in political, I guess, the political banter of health care right now. Words like equity and racism. I think that gets nothing done when you end up with studies that focus on, well, do we have a racism problem? Well, what would equity look like in this situation or that situation? I don’t want to waste money on stuff like that. I want to look at definable metrics. How can we affect the health of St. Joe County using definable metrics like infant mortality?”
But in drafting and debating the bill, lawmakers went to great lengths to protect local control, says Kim Irwin, administrator of the Indiana Public Health Association. The groups represents the interests of county health departments. Irwin also is one of the 16 members of the Governor’s Public Health Commission.
“I think it’s important to understand that what Senate Bill 4 allows is tremendous flexibility and locally prioritized implementation of this public health legislation, and how the money is spent and used,” Irwin said.
Irwin notes that while the bill requires participating counties to spend at least 60 percent of the new money on the new health problems, it doesn’t tell counties how to distribute that 60 percent across those areas.
But that doesn’t mean the new state spending won’t address the fact that minorities are more likely to die from things like chronic illnesses, suicides and overdoses.
“We know that issues of historic and structural racism and equity issues underpin most aspects of public health and so those issues and topics are embedded in all of what we do in public health,” Irwin said. “At the same time, again, local communities have tremendous control in how that plays out.”
County commissioners and council must vote to opt in to receive the new money. It was unclear whether they’ll do so in St. Joseph County. County Commissioner President Carl Baxmeyer and Council President Mark Root did not return repeated calls seeking comment for this story.
David Bottorff is executive director of the Association of Indiana Counties, which supported the bill.
He thinks most counties will participate, even if some want to wait and see how it works in other counties first.
“Really this is coming out of the state General Fund and so everybody, every taxpayer, pays into the General Fund,” Bottorff said, “and if a county chooses not to participate, their taxpayers are still contributing to the expansion of a health department in another county.
“We feel like there’s maximum flexibility in how counties appropriate the money and what programs they decide to strengthen.”
Counties have until Sept. 1 to opt in to receive funding starting in January.
