Public Health
by Griffin Beronio
What's the Problem?
Local health departments are responsible for delivering comprehensive care in a post-pandemic environment yet often lack the necessary resources to navigate state and federal mandates. The 2023 Consolidated Appropriations Act (CAA) “unwound” 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 (see Progov21’s Home Rule roadmap for resources on preemption). Access to reproductive healthcare is also being attacked at the federal and state levels, especially following the US. Supreme Court’s 2022 decision in Dobbs v. Jackson Women’s Health Organization. Local governments must overcome these barriers to protect bodily autonomy and create environments that improve public health outcomes.
Meanwhile, many healthcare recipients face serious hazards due to difficulties with accessing care in a comprehensive and equitable way. States with preemptive policies are more likely to have smaller gains in life expectancy and quality of life. At the same time, persistent mental health, substance abuse, and food desert crises remain in communities nationwide. If local leaders are to champion public health, they must address preemptive restrictions, improve access to care, defend abortion rights, and invest in healthcare workers.
What are People Currently Doing?
Preemption
Local governments must navigate preemption to promote equity and address the unique healthcare needs of their constituents. ChangeLab Solutions’ 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.
Access
Municipalities should actively improve access to care for underserved populations to 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. Chicago has implemented the Health Equity in All Policies (HEiAP) initiative which integrates 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. Cities can also expand 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 Water Systems roadmaps for guaranteeing access to healthy food and clean water).
Meanwhile, to guarantee access to reproductive healthcare, local governments can require employers provide high-quality, affordable, comprehensive health insurance to workers and their families. Cincinnati updated municipal employee’s insurance plans to cover reproductive and sexual health necessities like birth control, STI testing, and abortion care. Municipalities can also provide funding for these services: Kalamazoo created the first Reproductive Health Fund to finance sexual, reproductive and gender-affirming health care. St. Louis passed an ordinance redirecting funds from the American Rescue Plan Act to their city’s Reproductive Equity Fund.
Cities and towns can also resist the criminalization of abortion by deprioritizing, defunding, or prohibiting criminal investigations, arrests, or prosecutions related to reproductive health. Boise, New Orleans, and Memphis have passed resolutions instructing local law enforcement agencies not to investigate or pursue abortion providers or people who’ve had abortions. Austin’s GRACE resolution prevents city funds from being used by local law enforcement to investigate, document, or share information about abortions, miscarriages, and reproductive healthcare. Chicago passed an ordinance prohibiting city agencies from participating in investigations or proceedings related to reproductive care in jurisdictions, making the city a safer option for traveling from out of state for abortion. District attorneys in Orleans Parish, Durham County, DeKalb County, Fairfax County, and various Texas counties have announced that they will deprioritize prosecuting people under state anti-abortion laws. Additionally, 68 prosecutors around the country have vowed to never prosecute individuals for having or providing an abortion.
Crucially, self-administered abortion medication remains available in most states, although the legal landscape is changing constantly. If/When/How and the Repro Legal Helpline are organizations that can be shared with the public and policymakers to help people stay up to date. Abortion medication is generally very safe, and the FDA has made them available nationwide without an in-person doctor appointment. While they are currently legal to receive through the mail and to possess, some states have prosecuted people for using these medications for their intended purpose. While this remains a legal grey area in some states, it is crucial for local communities and elected officials to monitor state and federal guidelines. Localities should keep constituents informed as to all options available to them. This National Institute for Reproductive Health toolkit provides a comprehensive analysis of proactive strategies used by local governments to respond to the Dobbs decision. Officials and agencies can also inform residents about online organizations committed to providing access to and information about self-administered medication.
Workforce
The lack of investment in healthcare workers across the country creates gaps in access to care and increases worker precarity. Municipalities should invest in training and incentives for healthcare workers to support a healthy and competent workforce. Paid sick leave policies like San Antonio’s sick and safe leave ordinance strengthen worker power, raise labor standards, and crack down on the abuse of worker’s rights. This guide includes language for comprehensive paid sick leave policies, which promote workforce health and safety and prevent the spread of communicable diseases. Local governments must also take steps to ensure abortion seekers and providers are protected from violence and harassment. New York City, West Palm Beach, Pittsburgh, and Louisville have passed ordinances creating “safe zones” around reproductive health clinics that prevent harassment, physically contacting medical professionals or clients, and the blockading of clinic doors. Bernalillo County prevents picketing homes of reproductive healthcare providers and Chicago has banned discrimination in employment and housing based on a person’s reproductive health decisions.
Taking it to the Next Level
When addressing both public and reproductive health, local policymakers must address disparities caused by race, social class, and gender identity. Compared to white women, Black women are four times more likely to die from pregnancy-related complications. A variety of factors may contribute to this disparity, including discrimination in the healthcare industry, leading Black women to receive poorer quality care than their white counterparts. ChangeLab’s framework for Supporting Equitable Community Engagement provides a comprehensive guide to promote collaboration between state and local health departments in addressing social determinants of health (SDOH). 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.
Allies, Advocates, and Advisors
Mayors Innovation Project, our sister organization, is a national learning network for mayors committed to shared prosperity, environmental sustainability, and efficient democratic government.