As policymakers begin to look beyond the immediate COVID-19 Public Health Emergency (PHE), the pandemic continues to pose unprecedented challenges to both public health and the broader health care system. The task of efficiently and equitably reaching communities – particularly those hardest hit by the pandemic – has required public health leaders and health system stakeholders alike to think outside of traditional silos and develop new and innovative ways to collaborate. In racing to deliver COVID-19 tests, vaccines, and treatments, the pandemic catalyzed new partnerships between state and local public health leaders, health care systems and providers, and community-based organizations.

Although the pandemic has spurred new collaborations, it has also revealed longstanding gaps in the nation’s public health infrastructure and disparities in access to care. Historic underinvestment in public health systems, a depleted workforce, and antiquated data systems are just a few of the challenges that have hindered the public health response to COVID-19. The demands of the pandemic have made it clear that the public health system cannot work in a silo to do the foundational public health work of communicable disease prevention; maternal, child, and family health services; access to and linkage with clinical care; and preventing chronic disease and injury. By finding innovative ways to combine the efforts of public health, health care, and community partners around common priorities, states can be better prepared to respond to the next emergency and develop sustainable approaches for preventing costly conditions that significantly impact individual health and community resilience.

As states continue to shift from COVID-19 response to recovery, it is critical that we incorporate lessons learned from the pandemic and work to build a modernized public health system that is robust, interconnected, and capable of both promoting the health of all communities and addressing the challenges ahead.  To support state leaders in these efforts, the National Academy for State Health Policy (NASHP), with support from the Commonwealth Fund, is launching a new project focused on improving cross-sector alignment, coordination, and collaboration between public health and health system stakeholders on key public health goals. Drawing on the input and feedback of a diverse state leaders working group, as well as key partners and public health experts, NASHP will develop a toolkit for state leaders and launch a 12-month learning collaborative in Fall 2022 to provide technical assistance to up to five cross-agency state teams as they identify and implement their public health modernization priorities.

What Is Public Health Modernization?

The U.S. public health system plays a critical role in protecting and improving the health of people and communities.  Although efforts to modernize and strengthen public health systems pre-date COVID-19, the pandemic revealed new urgency and opportunities for states to invest in public health infrastructure and craft new approaches advancing population health goals. NASHP’s public health modernization project will build on many of the important frameworks and recommendations that have guided the broader vision of a modernized public health system.  These frameworks include the Bipartisan Policy Center’s Public Health Forward: Modernizing the U.S. Public Health System, the Commonwealth Fund Commission on a National Public Health System’s Meeting America’s Public Health Challenge: Recommendations for Building a National Public Health System That Addresses Ongoing and Future Health Crises, Advances Equity, and Earns Trust, the Public Health National Center for Innovation’s Foundational Public Health Services and Public Health 3.0.

While these frameworks address public health modernization from different perspectives, each emphasizes the importance of building and sustaining partnerships with the health system, business leaders, faith-based leaders, and other community stakeholders in expanding access to critical preventive and health services.  By supporting states in de-siloing public health, NASHP will work to identify practical strategies for aligning health system and public health efforts around common priorities. State activities may include expansion of access to care in community settings and collaboration on high-level priorities, like reducing the incidence of HIV, maternal mortality, diabetes, and asthma. CDC’s 6|18 and HI-5 initiatives, as well as implementation of State Health Improvement Plans and tying health system investments to community-identified health priorities through Community Health Needs Assessments, serve as examples of cross-sector collaboration on key public/population health goals.

Key Priorities and Opportunities for Public Health-Health System Collaboration

Through informational interviews and convenings of the State Leaders Working Group, state leaders have provided a number of high-level priorities and modernization strategies. Experts and state leaders have emphasized the continued need for federal leadership and sustained, flexible funding to support baseline capacity, and identified the opportunity to leverage American Rescue Plan Act and other federal funding to invest in workforce, data systems, and mechanisms to align public health and health systems around common high-priority goals. Many are using these one-time investments to catalyze modernization approaches while seeking effective strategies to translate them into true systems change. Key priorities and opportunities raised by state leaders include:

• Expand and sustain on partnerships built during the pandemic: Partnerships developed during the COVID-19 pandemic between public health, state Medicaid programs, and other health system stakeholders helped break down the walls between health care and public health. Rather than allowing these partnerships to lapse, states can work to identify, institutionalize, and scale successful strategies to address other public health priorities.
• Develop flexible approaches across states: Each state is different, with unique public health infrastructures, health care ecosystems, political environments, public health challenges, and other factors shaping current and future cross-sector collaborations. While some states have launched full-scale transformation efforts through Medicaid 1115 waivers to address social determinants of health, there are a wide variety of policy levers that states can adopt to identify and work toward addressing foundational public health priorities with health care system partners.
• Identify common priorities between public health and the health system and coordinate interventions: CDC’s 6|18 Initiative sought to bring public health leaders, health care providers, and insurers together to invest in 18 proven interventions targeting six of the most common and costly health conditions. Likewise, states can catalyze action in the Venn diagram where public health and health system responsibilities overlap. There are many models and examples of cross-sector partnerships that have sprung up in response to urgent public health challenges, including addressing maternal mortality, HIV/AIDS prevention, overdose prevention, COVID-19 response, and more.
• Align Financing and incentives around population health goals: In a number of states, the growing role of value-based payment and accountable care structures have created opportunities to align financing and stakeholder efforts around social determinants of health, health equity, and other population health goals. Aligning accountability measures across systems, highlighting well-defined use cases, and making investments in community-based organizations that hire community-based workforce can further these efforts.
• Bridge information gaps between public health and the health care system: Improving bi-directional data exchange between public health, Medicaid, and other health care partners is a critical priority for aligning partners around health goals. Progress in the exchange of immunization data with Medicaid programs and other clinical partners to support COVID-19 vaccination efforts is a clear example of how many states have overcome barriers to work together on urgent priorities. In addition to continuing to invest in modernized, cloud-based data infrastructure to improve interoperability, states can expand use and expedite placement of Data Use Agreements between public health agencies, Medicaid programs, and other health partners.
• Engage communities and build community-based organization capacity: Virtually all state leaders highlighted partnership with communities as essential to success. Meaningful partnerships with local health departments, community champions, trusted partners and backbone organizations (that support aligned initiatives in community) center health needs, pinpoint disparities and target investments. Investments include building capacity for state-local partnerships to flourish: state agencies require staff, dedicated time, and effective approaches to meaningfully engage community, and community-based organizations (CBOs) need human and financial capacity to modernize, link to the health system and deliver effective services to all who need them.  Developing a shared infrastructure across partners, including referral platforms, can help support stakeholders working toward the same goals.

Next Steps

NASHP’s forthcoming public health modernization toolkit and learning collaborative is poised to support states in expanding the impact and reach of cross-sector collaborations on key public health priorities.  Participating states will examine opportunities and best practices for developing cross-sector governance structures, braiding resources from various funding streams, improving information exchange with key partners, and effectively engaging communities. NASHP will select up to five states teams through a competitive process to participate in a 12-month learning collaborative, featuring multi-state and individual technical assistance.  Teams will be comprised of decision makers in public health, health and human services, Medicaid, and other state officials (e.g., budget officers, social service providers, Diversity, Equity, and Inclusion leads, community engagement liaisons, and others).  A Request for Applications  (RFA) will be available in early August.

State Workgroup Participant List

Danny Avula
Commissioner
Virginia Department of Social Services

Natasha Bagdasarian
Chief Medical Executive
State of Michigan

Sara Beaudrault
Policy Analyst
Office of the State Public Health Director
Oregon Health Authority 

Cara Biddlecom
Deputy Public Health Director
Public Health Division
Oregon Health Authority 

Kris Box
Health Commissioner
Indiana Department of Health 

Jan Chamness
Director of Public Health Transformation
Kentucky Department for Public Health

Maria Courogen
Director of Systems Transformation
Washington State Department of Health

Brooke Cunningham
Assistant Commissioner
Health Equity Bureau
Minnesota Department of Health

Jatin Dave
Medical Director
MassHealth

Thomas Dobbs
State Health Officer
Mississippi Department of Health

Patsy Kelso
State Epidemiologist
State of Vermont

Jewel Mullen
Associate Dean for Health Equity
Dell Medical School
University of Texas at Austin

Scott Rivkees
Professor of the Practice of Health Services, Policy and Practice
Brown University School of Public Health

Linette Scott
Chief Medical Information Officer
California Department of Health Care Services

Betsey Tilson
State Health Director
Chief Medical Officer
North Carolina Department of Health and Human Services

Anne Zink
Chief Medical Officer
Alaska Department of Health and Human Services