University of Wisconsin–Madison

Public Health

Written by Harrison Starr and Diana McFarland

What's the Problem?

Local health departments are responsible for delivering comprehensive care in a post-pandemic environment and often lack the necessary resources to navigate state and federal mandates. The 2023 Consolidated Appropriations Act (CAA) “unwinded” the continuous Medicaid enrollment provisions established during COVID-19, leading to the disenrollment of millions of Americans. State preemption laws also limit local governments authority over issues in their own jurisdictions, undermining their ability to address public health challenges. For example, 13 states ban local food and nutrition policies, 10 restrict e-cigarette regulations, 43 limit local firearm safety measures, 25 preempt minimum wage laws, and 22 prohibit local paid sick leave ordinances. Local governments must overcome these barriers to create environments that enhance public health and improve outcomes. 

The IRS Community Health Needs Assessments show local communities face significant difficulties accessing care in a comprehensive and equitable way. For recipients of healthcare, these difficulties pose serious hazards. States with preemptive policies are more likely to have smaller gains in life expectancy and quality of life. Meanwhile, persistent mental health, substance abuse, and food desert crises remain in communities nationwide. For healthcare workers, the situation is equally dire, with the latter facing stagnant wages, union-busting, and unfair hiring practices. Progressive localities must do more to promote policies that improve health outcomes for their community members. 

What are People Currently Doing?

Preemption

Local governments must effectively navigate preemption to promote equity and address the unique needs of their constituents. The National League of Cities’s Principles of Home Rule for the 21st Century provides a framework to expand local authority and safeguard against arbitrary state preemption. This model legal structure strengthens local governments' ability to exercise greater autonomy. During the COVID-19 pandemic, Wisconsin’s Dane County Public Health leveraged home rule principles to enforce local public health orders through civil action. These orders included social gathering mandates and mask requirements to mitigate contagion. The ordinance was challenged in Becker v. Dane County, but the court upheld the county’s actions, affirming the local ordinance did not conflict with state law. A similar case illustrating home rule principles was Kirk v. City of Morgan Hill, in which the court upheld a local ordinance regarding stricter gun regulations than California state law. These cases stress the importance of understanding state authority and leveraging legal frameworks to address local challenges. 

ChangeLab Solutions’s report on social determinants of health (SDOH) serves as a resource for state, local, and territorial health departments to address legal challenges related to preemption. The Ten Essential Public Health Services provide strategies to identify health problems, address them through policies and practices, and communicate effectively with the communities they serve. Localities have successfully enacted proactive public health initiatives, even in preempted areas such as tobacco control, despite state-imposed limitations. Local health departments can often exercise “police power” through legal and regulatory action to address SDOH and the public health deficit. This authority enables them to administer programs that promote health access, bolster the healthcare workforce, and encourage collaboration among health departments. Home rule policies must balance the common good with constitutionally protected individual rights to ensure they are legally upheld. See ProGov21’s Home Rule roadmap for additional strategies regarding state preemption.

Access

Municipalities also have significant opportunities to improve access to care for underserved populations and reduce health inequities. The Foundational Public Health Services Framework identifies specific local programs and public health infrastructure to improve health access and promote public health. Several cities apply the conceptual framework of foundational areas to administer community-beneficial and equitable health programs. Chicago has implemented the Health Equity in All Policies (HEiAP) initiative which crosses institutional boundaries and unites local government programs. HEiAP is dedicated to integrating public health into neighborhood planning, housing, food access, and environmental policy. The Los Angeles Code Application Notice provides a clear framework to zone and create new healthcare facilities in urban environments. Ride to Care is a free non-emergency medical transport service in Oregon that ensures equitable access to medical care for residents without reliable transportation. These programs demonstrate how municipalities can leverage foundational public health strategies to enhance connectivity and equity. 

Smaller municipalities and counties with fewer resources may find large-scale programs less feasible, but can still have a significant impact on the health of their residents. Alternative approaches to public health access include expanding healthy food access through urban agriculture or farmers markets, mental health navigation services, and community support groups focused on substance abuse recovery and prevention. See ProGov21’s Food and Integrated Water Management roadmaps for strategies on providing healthy food and clean water to communities. 

Workforce

The national lack of workforce investment and retention creates a gap in equitable access to care. Municipalities should invest in training and incentives for healthcare workers to support a healthy and competent workforce. Addressing paid sick leave, for example, allows governments to promote policies that strengthen worker power, raise labor standards, and crack down on abuses of worker’s rights. This guide models language for comprehensive paid sick leave. San Antonio passed a paid sick and safe leave ordinance that ensures any employee pay because of them or their family’s health. These policies not only promote the health and well-being of the public health workforce but also prevent the spread of communicable diseases and ensure the health of the community as a whole. 

Taking it to the Next Level

The emergence of civic technology provides innovative tools for collaboration and alleviates the burden on healthcare workers, caregivers, and those navigating public health programs. Digital Public Goods Alliance provides a registry to facilitate the discovery, development, use of, and investment in digital public goods in alignment with the United Nations’ Sustainable Development Goals. These tools provide trusted civic technology from international organizations to promote public health outcomes, including training and collaboration tools for local health departments. A guide on improving local health department’s websites provides tips to increase access to local public health through civic technology. Meanwhile, Polly, Polco’s AI-powered partner, provides data-driven insights and a planning tool to better equip community leaders, government officials, and public sector managers. These innovations empower local elected officials to make better decisions, deliver more equitable and accessible public health outcomes, and ensure caregivers and receivers access the healthcare they need.

ChangeLab’s framework for Supporting Equitable Community Engagement provides a comprehensive guide to promote collaboration between state and local health departments in addressing SDOH. A clear guide is necessary to understand the roles for leaders and collaborators in health departments, establish clear community engagement approaches, create funding mechanisms, and train employees in an equitable and accessible way. Health in All Policies (HiAP) is a system in place that executes ChangeLab’s framework in addressing SDOH at the local and state level. It provides a process for collaborative cross-sectoral work to improve community health and address health inequities. The California HiAP task force, for example, serves as an excellent case study of the first tactical implementation of HiAP. The task force has provided a framework for addressing health inequities through HiAP since 2010. 

Local governments are uniquely situated to ensure the health of their communities. The key to equitable and accessible care is collaboration between legislators, the workforce, and local advocacy organizations. A mutual commitment to improve public health paves the way for communities to overcome disease, increase life expectancy, and ensure positive health outcomes for all residents involved.

Helpers, Allies, and Other Useful Organizations

  • ChangeLab Solutions is a nonprofit organization that partners with communities across the nation to improve health equity by changing harmful laws, policies, and systems.
  • The Mayors Innovation Project is a national learning network for mayors committed to shared prosperity, environmental sustainability, and efficient democratic government.
  • Safe Routes Partnership ​​is a national nonprofit that works to create livable, sustainable communities where all people can be healthy and physically active through safe walking and bicycling.
  • The Greenlining Institute is a nonprofit organization that seeks to advance economic opportunity and empowerment for people of color through advocacy, community and coalition building, research, and leadership development.

Mayor's Innovation home page

Mayors Innovation Project, our sister organization, is a national learning network for mayors committed to shared prosperity, environmental sustainability, and efficient democratic government.

Visit MayorsInnovation.org

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