Jan 19, 2023
The public health community readily welcomed last summer’s news of the CDC’s “Strengthening U.S. Public Infrastructure, Workforce, and Data Systems” Notice of Funding Opportunity (NOFO). While COVID-19 had elevated the public health workforce in the minds of policymakers and the public, as a community, we were already well aware that a sizeable investment in public health was long overdue — and desperately needed.
With $3 billion of the $4 billion (over five years) going specifically to workforce hiring, retention, and professional development, this is an historic investment in state and local health departments by the federal government. But there are reasons to be concerned about the impact that this short-term funding could have on the long-term wellbeing of the governmental public health workforce.
In the best-case scenario, state and local health departments receive this flexible funding and use it as intended to invest in growing their workforce. Community members and state and local policymakers note the additional funding’s impact: more expansive programs, better health outcomes, and money saved. When the five years are over, the public and political desire and will exists to support the use of state and local tax revenue to sustain the same workforce levels and the improved services and outcomes persist.
Unfortunately, with best-case scenarios, so much needs to go right, when so much can go wrong.
The problem with temporary funding is that it’s temporary.
It is difficult to hire someone permanently when the money is temporary. Many health departments may choose to hire temporary staff to fill the newly funded positions, working with temp agencies or workforce extender nonprofit organizations with which the department has a relationship.
Because the federal funding clearly states that the new positions should be paid a fair wage — potentially higher than current government pay levels — existing workforce members already demoralized by the experience of the past three years could, understandably, become even more resentful, contributing to their further exodus.
It is worth noting that inefficiencies with government hiring processes provide further incentive to hire a temporary workforce. It can take a long time — often months — to fill permanent civil service positions.
Short-term funding could create long-term expectations that can’t be met. Over the next five years, communities could become accustomed to expanded public health resources and improved outcomes. When the funding period is over, permanent public health department staff may feel even greater pressure to provide services for which there is no funding.
And while the investment is significant, it still isn’t enough. The funding is still a small percentage of the money that’s needed to get us where we need to be for an effective public health infrastructure in all states.
We’re not very good at tooting our own horn.
The public health workforce, a humble lot, is not good at promoting what they do; they tend to stay behind the scenes. As a result, when they are in the news, it’s because something bad has happened — like an uncontrolled disease outbreak — for which the public and policymakers choose to blame them in their effort to pin the responsibility on someone other than themselves.
While significant and sustained advocacy from the public health community led to this CDC funding, at the local level, the public health workforce will need to show their communities and policymakers that their efforts have led to better outcomes and to demand ongoing investment.
There must be a measurable return on investment.
Beyond increasing awareness at the local level, gathering the data and evidence to demonstrate that there has been a return on these investments will be a significant part of this work. But the funding for evaluation is inadequate. It is difficult to measure the impact of a public health initiative in the short-term, but if we do not demonstrably prove a return on investment, we could be back at square one, with policy makers questioning what the $3 billion in funding achieved.
State policymakers could choose to offset state and local spending with this federal money.
While the intention of the CDC funding is to be additive and to bolster the workforce, state policymakers — particularly those confronting decreased revenues resulting from a recession — could decide to offset state and local funding with federal money.
This is the biggest risk of all. When the federal funding is gone and state and local funding does not return, states may find that they have depleted the workforce permanently.
Although the CDC guidelines are explicit that the funds cannot be used for other purposes, it is clear that it is already happening. If the funding stays within the public health departments, it could be used to address an important need that the state has identified, but that may not be the public health workforce, despite it being central to the success of any efforts.
There is a history of new funding intended for public health being used for other purposes or substituted out for permanent funding. The quintessential example is the Prevention and Public Health Fund, created under the ACA for the purpose of population-based prevention. While, again, the CDC is clear in its guidelines about their desire to avoid this substitution effect, states can choose to interpret these rules in ways that are self-serving.
States could leave the money unspent.
Recent reporting revealed that nationwide— by this past December — states had spent less than 20 percent of the $2 billion in funding intended to bolster the COVID workforce, despite many states “struggling mightily to use the money.” With budgets having been slashed by state legislators and public health worker compensation kept at unappealingly low levels, states like Mississippi were not in the position to turn on a dime and attract the volume of skilled workers they desperately needed.
We need to be vigilant.
The public health community needs to be vigilant in response to the possible negative effects of what should be a positive opportunity.
There is a well-documented pattern of government throwing a little bit of money at public health in response to a public health disaster. In fact, it’s the funding model for public health: panic, neglect, repeat. (See COVID, Zika, Ebola, swine flu.) But, if we do it right, this funding could demonstrate what a permanent investment could achieve.
We need to focus our efforts on permanent funding for public health departments. We need to elevate governmental public health workforce wages to competitive levels. And we need to fix the hiring process so that it doesn’t take six months to get started on a job.
When I wrote my dissertation about the employment outcomes and employer demands faced by public health school graduates in the United States, I used the metaphor of a leaky bucket into which we keep pouring more and more water, without taking time to fill the holes.
Will the new funding allow lead us to be able to patch those holes or will we just add more water to the leaky bucket?
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