Today’s Urgent Leadership Challenge: State-Level Public Health Advocacy

Introduction Public health in the United States is at a critical juncture. With increasing political polarization and shifting federal priorities, state-level public health initiatives are essential in maintaining and advancing the public’s health. At the same time, public health itself has very few dedicated advocates at state and local levels. As noted in a prior Management Moment column, advocacy must be a core skill for public health leaders.1 A recently released 50-state Scan of Public Health Advocacy Capacity2 and an earlier summary report3 now provide crucial insights into the challenges and opportunities faced by public health advocates, offering a roadmap for strengthening advocacy efforts across states. By examining successful examples from politically diverse states (Colorado, Indiana, Massachusetts, Montana) and leveraging key partnerships with advocacy organizations, public health practitioners can influence policy and protect health. The Political Landscape and Public Health Public health policies have long been subject to political influences, impacting funding, legislative priorities, and overall effectiveness.4 Over the past 50 years, public health has had both significant policy successes such as the Tobacco Control Act of 2009 as well as reversals, such as the rollback of the 2014 Clean Power Plan which aimed to reduce carbon emissions from power plants, and modifications to the Affordable Care Act, disproportionately affecting marginalized and historically resilient communities. COVID-19 further exacerbated these challenges, intensifying public distrust and spawning legislative measures that limit public health authority in a number of states. Since the US Constitution does not explicitly address health services, in many situations the states still have tremendous influence over the public’s health.4 This means state-level advocacy is a crucial tool for advancing public health policies. The newly published 50-state Scan of Public Health Advocacy Capacity provides a valuable resource for understanding state-specific public health landscapes and identifying strategic advocacy opportunities both nationally and in individual states.2 The Indiana Success Story: Lessons in Advocacy One of the standout examples of successful public health advocacy is Indiana: a state with Republican supermajorities in both legislative chambers that achieved significant public health victories through policy and strategic advocacy.5-7 In 2021, Governor Eric Holcomb established a Public Health Commission to review the state of public health in Indiana and make recommendations for improvements. This led to a remarkable achievement – a 1500% increase in public health funding approved by the Indiana General Assembly in 2023, allocating $225 million over 2 fiscal years with over 90% of counties participating.5,6 The success in Indiana underscores several key advocacy strategies: Engaging Elected Officials Early: The governor’s establishment of a commission with broad representation to assess public health needs fostered bipartisan support. Framing Public Health in Non-Partisan Terms: Advocates used economic and workforce-related arguments to appeal to a broad, bipartisan audience including conservative legislators. Building Local Partnerships: Community engagement ensured broad-based support, making it politically viable for legislators to back increased funding. Colorado, Massachusetts, and Montana are states with different models for building state-level capacity to advocate for the public’s health as described in detail elsewhere.2,3 These approaches demonstrate how state-level public health advocates can navigate political challenges and achieve substantial policy wins, even across politically diverse states and localities. How Can We Strengthen Advocacy for the Public’s Health? The findings from the 50-state scan highlight several challenges and opportunities for public health advocacy: 1. Addressing and Overcoming Reluctance in Public Health Advocacy Many public health professionals hesitate to engage in advocacy due to concerns about lobbying restrictions or a lack of experience in political engagement. Training public health leaders in allowable advocacy strategies and fostering partnerships with lobbying organizations can help bridge this gap.8 Advocacy must be recognized as an essential skill for public health professionals, as their expertise can significantly influence policy decisions. 2. Countering Challenges to Public Health Authority The COVID-19 pandemic triggered numerous legislative efforts to curtail public health powers. Between 2021 and 2022 alone, 17 states enacted laws limiting public health authority, with six states reallocating power away from health agencies.6 Within this context, effective advocacy strategies may include: Highlighting Economic Impacts: Demonstrating how public health policies contribute to economic stability can build bipartisan support. Leveraging Local and State Success Stories: Sharing examples from states like Indiana can help counter anti-public health narratives. Engaging Diverse Stakeholders: Forming coalitions with business groups, faith-based organizations, and community leaders who can reach out to their elected officials in support of public health can also yield positive results. 3. Promoting Health Equity Through Strategic Messaging Health equity remains a fundamental but politically sensitive issue. Advocates have successfully used terms like “non-medical drivers of health” and focused on economic and workforce impacts to gain legislative support. By adapting messaging to local contexts, public health advocates can advance equity-focused policies without triggering opposition. 4. Enhancing Collaboration With Public Health Allies Public health advocacy benefits from collaboration among non-governmental organizations, academic institutions, and private sector partners. Strengthening ties with entities that have lobbying capacity, such as state hospital associations and business groups, can amplify and validate public health’s essential services. The state scans showed that the American Heart Association, American Cancer Society, and groups like the AARP have advocates in nearly every state. Multi-sector coalitions can provide a unified voice in policy discussions, increasing the likelihood of legislative success. We Can’t Afford NOT to Advocate for Public Health As public health practitioners, we certainly have no shortage of items on our “to do lists.” From preparing for the next pandemic to addressing opioid and suicide crises to fighting for healthier communities with affordable housing and a safer climate, it may seem unrealistic to add advocacy to the list. Yet we continue to see the authority and funding of public health agencies being stripped away. Support for essential public health protections like vaccines and fluoridated water continues to decline due to disinformation campaigns. These trends will lead to failure to protect the public’s health. The authors encourage public health leaders to set aside time each week to engage in advocacy work, such as working with board of health members on an advocacy initiative or partnering with the chamber of commerce to cultivate allies for public health in the business community. By forming these community-based partnerships for health, public health practitioners can advance their advocacy agenda and better protect the health of the communities that they serve. We, as public health practitioners, are best positioned to fight for the public’s health, and we now have the tools to do so.