I read the Indiana Governor’s Public Health Commission report in its entirety so you don’t have to (Part 2: Public Health is Local)

Part 2 TL;DR: In Indiana the 94 Local Health Departments determine public health services. Because they are mostly locally funded, they vary greatly in the services they provide- this can and should be remedied by the Statehouse this year

Gabriel Bosslet
5 min readDec 14, 2022

In part 1 of this series, I demonstrated how woefully underfunded public health is in Indiana and how it is within our grasp to flip the script with improved funding (without a need for tax increases).

The extent to which public health is underfunded at the state level was a real eye opener for me. But I was floored when I read to what extent public health is locally funded in Indiana and what that means for local health departments.

(Much of the following came from the Indiana Public Health System Review, published in December, 2020 by the Indiana University-Purdue University Indianapolis Fairbanks School of Public Health. It is really great work. Anything that should have citations in this piece can be assumed to come from this report unless otherwise stated.)

Local Health Departments are where public health really happens in Indiana

Indiana public health is delivered under a decentralized model. Local (usually county) governments essentially operate and fund Local Health Departments (LHD) autonomously. They interact with the Indiana Department of Health on some issues, but mostly operate on their own. This has advantages and disadvantages (see below table).

List of advantages and disadvantages to Indiana’s decentralized public health governance model
Source: https://www.in.gov/health/files/GPHC-Report-FINAL-2022-08-01.pdf

There are 94 LHDs throughout Indiana- 91 are county-based and 3 are city health departments (Fishers, East Chicago, and Gary). These LHDs are tasked by Indiana statute with providing a variety of mandatory health services for the citizens they serve (see figure below).

Source: https://www.in.gov/health/files/GPHC-Report-FINAL-2022-08-01.pdf

You may look at this list and say “wait they do all THAT?” Well, they are supposed to. But in Indiana because of the abysmal funding of Local Health Departments (more on this below), they are only able to provide about half of the 20 recommended public health services. (Of course this is the case- overall Indiana state funding for public health is 50% below what it was in 2004)

Map of indiana showing that Local Health Departments are only able to provide about half of the 20 recommended public health services
Indiana Local Health Departments are only able to provide about half of the 20 recommended public health services. Source: https://fsph.iupui.edu/doc/research-centers/indiana-public-health-system-review-fnl5-web.pdf

Local Health Departments in Indiana are locally funded- which means there are HUGE discrepancies in the amount of public health resources depending on where you live

In Indiana, almost 75% of funding for LHDs comes from local revenue- the general county fund or local taxes earmarked for public health services. This is different than most other places- across the U.S., the average proportion of funding to LHDs that comes from local government revenue is only 25% (page 47).

Because most of the funding is from local sources, there is a HUGE discrepancy in per-capita LHD revenue. Marion county has public health revenue of over $80 per citizen. Shelby County has $1.25 of public health revenue per person. This is a crazy amount of variation (see the chart below, which blew my mind).

Table of county per-capita public health revenue which demonstrates a HUGE variation.
The most well-funded county (Marion) has 66x the per-capita public health funding of the worst-funded county (Shelby).

This amount of public health revenue variation means that multiple Local Health Departments are spending less than a cup of coffee per year on each resident under their jurisdiction. It is hard to move the needle on substance abuse, maternal mortality, infectious disease outbreaks, and sanitation on less than a cup o’ joe.

The amount of LHD funding variation in Indiana is CRAZY. But just as crazy is the fact that 90 of the 94 LHDs in Indiana are funded well below the 25th percentile nationally. It is entirely possible that Shelby and Jennings Counties spend less on public health per capita than any other county in the country (I can’t find those data to compare).

Indiana should keep public health decentralized but offer better state funding for those LHDs that want to improve public health outcomes

I actually think the decentralization of public health services is a good thing. Public health efforts require local buy-in and trust, and the thought of sending someone from Indianapolis to other counties around the state to provide needed public health services would go over like a lead balloon (as it should).

And decentralization obviously means allowing local governing bodies to decide on their own priorities regarding spending and their attitude toward public health. If a local government wants to spend less than a Snickers bar per citizen per year on public health, that is up to them. But I suspect there are plenty of local LHDs and governments that would love to be able to provide more services in a more robust fashion.

If you would rather live in a place with more public health services than you currently have, there will be bills debated in the legislature in January to address this. Start talking to your state Senator and Representative today and once the bills are drafted the Good Trouble Coalition will provide information on these bills and language to talk about them if needed.

In my last post I demonstrated that providing state-level funding to bolster local LHD revenue is fully possible with our current spending levels without changing taxes for anyone. We need but have the will to improve public health. The money is there.

You can help support public health and health equity advocacy in Indiana by supporting the Good Trouble Coalition, a grassroots group of Hoosier healthcare and public health stakeholders who collaborate to educate, empower, and facilitate political advocacy in the areas of patient-centered care, public health, and health equity.

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Gabriel Bosslet

Gabriel Bosslet is a a pulmonary and critical care physician in Indianapolis. He is a co-founding member of the Good Trouble Coalition.