I read the Indiana Governor’s Public Health Commission report in its entirety so you don’t have to (Part 1)

Part 1 TL;DR: Indiana underfunds public health despite collecting the revenue to properly invest in public health- improvements in meaningful public health outcomes will not happen without Statehouse investment in Hoosiers

Gabriel Bosslet
5 min readDec 12, 2022

In August, 2021, Indiana Governor Eric Holcomb issued Executive Order 21–21, which convened a commission to provide counsel on the state of Public Health in Indiana.

The Commission issued its report on August 1, 2022. There were multiple “holy shit” moments for me as I read it. I will summarize the larger findings over a couple of posts here and contextualize the recommendations for this coming legislative session.

The backdrop for the Commission’s work is a falling life expectancy for Hoosiers and a significant rise in death rates in the younger age groups. You can read a terrific piece by Matt Kinghorn in the Indiana Business Review about the details of our declining life expectancy. But obviously a falling life expectancy is a major red flag in public health.

Indiana citizen life expectancy is decreasing and is falling behind the national average since the 1990s.
Source: https://www.ibrc.indiana.edu/ibr/2021/summer/article1.html

The Commission report is detailed and amazingly well researched. It includes recommendations in six subject matter areas- I will not talk about all of them here, but will focus on the “low hanging fruit”- starting with overall funding of public health.

Indiana massively underfunds public health- both from the state government and federal grant dollars

The most striking finding in this report is the extent to which Indiana has neglected investing in the health of its citizens.

In 2018–2019, the last year before the pandemic, the average state in the US spent $91 per citizen on public health funding. Indiana spent $55. We invest only 60% of what the AVERAGE STATE did in 2019 on public health. And the amount we have spent per capita has been cut in half (in 2022 dollars) since 2004. We spend a small amount and have been shrinking that amount greatly over time.

Indiana has cut state funding for public health efforts in half since 2004 (Credit to for the visualization)

But this only tells part of the story. Most Indiana public health spending does not come from it’s own coffers- it comes from public health grants from the Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC). If we look at the amount of money spent per capita on public health from Indiana coffers, we only spend $15 per Hoosier on public health. The rest of the $55 quoted in the report (73%) comes from CDC and HRSA grants. In other words, only 27% of Hoosier public health funding comes from the Statehouse. The rest comes in the form of federal grants. The national average of total public health spending that comes from state coffers is 38%.

Low state coffer public health spending compounds itself. Federal public health grant funding is directly related to the amount of state spending- the more a state spends on public health, the more federal dollars come to that state for public health interventions. Indiana ranks 40th among states for per capita HRSA funding and 50th among states for CDC funding.

Another way to put it: nationwide, every $1 in state public health funding brings in another $2.64 in federal public health money. (Don’t get me started on the downstream health savings of public health interventions.)

Graph showing that state funding for public health is directly proportional to federal grant funding for public health to that state

Why is this the case? Because public health entities have to pursue federal grants- they aren’t just given out automatically. If we are underfunding public health, we have no one to apply for grants and collect data to justify that grant funding. So we miss out on federal dollars because we don’t spend any state dollars to create the infrastructure to obtain federal support.

Underfunding public health has real world consequences

Last week was the annual “Labor of Love” conference, held annually since 2012 to focus on improving maternal and infant mortality. The results have not been good. Over the last 10 years, Indiana remains 42nd in infant mortality (death within a year of birth) and maternal mortality rates have only worsened over the past decade.

Pregnancy-associated (within 1 year of pregnancy, death related to pregnancy) and pregnancy-related (within 1 year of pregnancy, irrespective of cause) deaths have been rising since he definitions and data collection methodology were standardized in 2018 (cannot compare prior to that).
Pregnancy-associated (within 1 year of pregnancy, death related to pregnancy) and pregnancy-related (within 1 year of pregnancy, irrespective of cause) deaths have been rising since he definitions and data collection methodology were standardized in 2018 (cannot compare prior to that). Source: https://www.in.gov/health/cfr/files/MMR-Report-September-2022.pdf

Indiana remains in the bottom 1/3 of states when it comes to overdose deaths.

We are 34th in the nation in firearm death rates.

We are 39th in the nation for COVID-19 death rates (in the last quarter). We are 41st in the country for number of residents fully vaccinated (57%, national average 68%).

We are 37th in the United States for teen birth rate.

These outcomes mean Indiana’s residents suffer more than needed. It also leads to significant downstream state health costs.

Indiana has the revenue to adequately fund public health efforts

The Governor’s Commission report suggests that Indiana should consider investing an additional $246 million of state funding per year in public health funding, which would bring the state up to median 2019 per capita spending in the United States.

There are reasonable arguments as to why this may not be a good way forward (all of which I disagree with). But one argument which holds very little water is one which suggests that we cannot afford it.

Indiana has had a budget surplus in all years but 2020 (the pandemic year) since 2010. The average budget surplus (including the deficit in 2020) during that time is $677 million dollars- far more than the $246 million that the Governor’s Commission has suggested would be appropriate.

Indiana has an average yearly surplus of $677 million since 2010 (visualization by )

This summer, given the fact that Indiana had a $6 billion surplus, the Governor called the legislature to refund each Hoosier taxpayer $200 (you may not remember this- the special session was dominated by the abortion ban debate). This amounts to $1 billion- Indiana could have funded 4 years of the suggested increase in public health funding with these funds.

This year is a budget session- and the Indiana legislature should support the Governor’s Commission and fully fund public health- history tells us we could do this without a tax increase

Public health issues are complicated issues without easy fixes. Public health policy is a messy combination of medicine, law, sociology, economics, and education.

Improving public health means accepting that everyone is not perfect and meeting them where they are. It means understanding the world as it is, not as it should be. It is important.

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.