Public health policy is defined as the laws, regulations, actions, and decisions implemented within society in order to promote wellness and ensure that specific health goals are met1. Historically, public health legislation has focused on addressing existing and emerging threats to the health of the public; however, current conversations around transformation have shifted attention to how states are modernizing their governmental public health systems to create equitable systems and communities now and in the future.

As one of the core functions of public health, policy development is essential since legislation and policies affect almost every aspect of public health practice, including preventing the spread of communicable disease; ensuring food, air, and water quality are safe; supporting maternal and child health; improving access to clinical care services; and preventing chronic disease and injury. Public health departments have a fundamental responsibility to provide public health protections and services, yet the infrastructure needed to fulfill these responsibilities is historically and chronically underfunded and outdated. Recent investments in public health transformation, like the CDC’s Public Health Infrastructure Program, have provided a greater opportunity for governmental public health departments to focus on building the Foundational Public Health Services (FPHS) needed everywhere for public health to work anywhere.

PHAB is the home of the FPHS and the 21st Century (21C) Learning Community, which is a group of statewide public health systems transforming public health practice. These states have used the FPHS and other transformation-related language/frameworks in legislation to ensure a minimum set of Foundational Capabilities and Foundational Areas are available in every community. Additionally, health departments in these 21C states are using legislation to explain the role of governmental public health, assess capacity and resource gaps, determine the cost for assuring foundational activities, and identify funding needs.

Important initial steps in developing legislation around transformation is defining what the governmental public health system is comprised of, developing an understanding about its essential role, and understanding the need for change among key governmental public health leaders and other partners. The groups that should be engaged in this work can include state, local, and Tribal leaders, legislators and other elected officials, healthcare delivery partners, business leaders and other state or local policy influencers, and stakeholders, including the general public.

Several 21C states that have enacted transformation legislation specifically outline the governmental public health system in statute. For example, Oregon’s system consists of the Oregon Health Authority Public Health Division and local public health authorities, as defined in the Oregon House Bill 3100 (2015). Likewise, Washington’s system is comprised of the state department of health, state board of health, local health jurisdictions, sovereign Tribal nations, and Indian health programs, as defined in the Revised Code of Washington 43.70.512.

Several 21C states have also established definitions for their national or state-specific FPHS model in statue. For example, the Code of Colorado Regulations 6 CCR 1014-7 outlines its Core Public Health Services framework made up of seven foundational capabilities and five foundational services. Likewise, the Wisconsin Administrative Code Chapter DHS 140 was updated in 2019 to incorporate aspects of the FPHS framework into the state’s required services of local health departments.

The next step several 21C states have included in legislation is the ability to assess the current capacity and coverage of the governmental public health system to deliver the FPHS using data from each health department. Using assessments like PHAB’s Readiness Assessment or the FPHS Capacity and Cost Assessment, health departments or public health systems can estimate the gap between current investments and capacity and what would be needed for full implementation of the FPHS. This provides a current snapshot of the system, which is important for legislatures to see how investments would be used today and in the future.

For example, Minnesota House File 33, which is the state’s omnibus health and human services bill, provides $3 million from the general fund to assess the capacity of the public health system to meet national public health standards and oversee public health system improvement efforts. Likewise, Oregon House Bill 3100 (2015) outlines the core functions of the governmental public health system and articulates the separate, but mutually supportive roles for state and local public health authorities to conduct a statewide public health modernization assessment.

A handful of 21C states have determined key next steps once they’ve completed the assessment, including determining how to fully implement the FPHS through funding. This requires a process to engage policymakers and to prioritize any policy changes and funding requests, such as:

• Increased funding for the governmental public health system overall.
• Funding and/or service delivery changes to strengthen the FPHS Capabilities and Areas.
• Funding and/or service delivery changes to increase capacity to address current high priority health issues.
• Funding and/or service delivery changes to better address health inequities.
• Funding and/or service delivery changes to address Capabilities or Areas that could use resources immediately and get results in 12-24 months (to fall within the length of a legislative session).

For example, the Kentucky Revised Statute 211.186 (2020) establishes a new funding formula for local health departments to deliver foundational public health programs, including options to share services with other public health agencies. Likewise, the Indiana Senate Enrolled Act 4 (2023) creates the Health First Indiana initiative, which provides core services funding for local communities to prioritize public health and safety.

While not all 21C states have developed legislation for transformation, some have laid the groundwork for exploration to modernize their public health systems. For example, the New Mexico House Memorial 2 established a public health task force that will recommend strategies for improving public health infrastructure in the state.

In the absence of formal policy actions, some 21C states have charted a path toward transformation through the creation of task forces, coalitions, and initiatives that envision a modernized governmental public health system that is equitable, efficient, and effective at improving the health of all. Additionally, some 21C states are leveraging federal funding streams, like remaining American Rescue Plan Act dollars and the new Public Health Infrastructure Program dollars, to support critical public health infrastructure needs focused on addressing the public health workforce, strengthening and enhancing Foundational Capabilities, and data modernization activities.

More legislative and general information on the 21C states mentioned above, as well as others that are part of 21C, can be found on the PHAB website. If you are not a part of 21C and have transformation legislation in your state, please contact [email protected] to share those details.