Share Public Health Transcript: Advocacy, We Have to Ask for What We Need

Season 2 Episode 4

Deborah Thompson: Welcome to Share Public Health, the Midwestern Public Health Training Center’s podcast connecting you to topics, issues and colleagues throughout our region and the country that highlight what we all share in public health. Thank you for tuning in to this series that focuses on public health advocacy.

Hey, public healthers, thank you for tuning into this episode of Share Public Health. My name is Deborah Thompson, I’m a public health advocate, and for eight years, I was the point of contact for legislators at Iowa State Health Department. These days I spend my time as an advocacy consultant and as a volunteer for the Iowa Public Health Association’s advocacy committee with my dear friend Hannah Shultz. Hannah is the producer for this podcast series, and I’m your host. This is the third of four episodes about advocacy. In this series, we’ll explore the motivations public healthers all over the Midwest feel about advocating for their craft. They’ll give us advice on how to be successful and they’ll ask that you consider finding your voice to aid in our collective efforts to promote and improve the health of the Heartland. Thanks for listening. Today’s episode focuses on advocating for funding. Man, do we need funding, dollars, resources, appropriations, allocations, backing, support, investment, whatever form it comes in, we need more of that in public health. The pandemic is a blessing and a curse in this regard. The public health system in the United States has proven to be too anemic to provide the proper response that Americans deserve from their government. Well that, and other factors that are out of our control, [clears throat] – politics. Anyway, because of this, we have an opportunity to ask for more, a larger share of that pie that makes up America’s vast wealth. Our guests today will discuss where to ask for more and how to go about it. Our first interviewee is Matt Wyant. Matt is the Director of Planning and Development for Pottawattamie County in the state of Iowa. He oversees the Public Health Department, too. Matt unexpectedly found himself in the middle of an opportunity when the Pottawattamie board of supervisors and the city of Council Bluffs decided to merge the city and county health departments. It’s funny how the universe works, though, Matt seems to be the exact right person to lead this effort. Why? Well, because he thinks outside the box, is planning for the future of public health, and he immediately understood the need for the county to improve their health standings, so they can improve their economic outlook. Matt has spent a lot of time advocating for private foundation funding in an effort to diversify funding streams for his public health budget. This has led to better partnerships, which has led to increased opportunities, and which will inevitably lead to better health outcomes. Okay, it’s time for Matt to tell the story, not me.

Matt Wyant: I am the Director of Planning and Development, I oversee the Public Health Department, and I’ve been with Pottawattamie County for 14 years, I believe it is now, and we have been in the health department business since 2016. I was appointed as the interim director of the planning department in 2015 and became the director in 2016. During that time, we had been undergoing a revamping of our transfer station, which was where everybody takes their solid waste to rurally in Pottawattamie County. Through that process, we had an independent study done, I formed a citizen task group that came together to review the study to see how we could better handle solid waste issues in Pottawattamie County. And out of it came the idea of a recycling center to be constructed for Pottawattamie County. Internally in the citizen task force were people who had worked with a local fundraising company, and they suggested that I meet with Lisa Fox who owns Fox Creek Fundraising, and discuss with her what the county was looking at and what she thought for possibilities on funding opportunities for that facility, and the relationship really kind of grew out of that initial get-together on the recycling center. And as the health department came underneath the county jurisdiction, it expanded out through there and all of the different initiatives that we undertook from the health department side.

Deborah Thompson: Matt’s networking led him to a private company who could open doors for him, but he still had to seal the deal. How? By understanding his audience. Matt didn’t sell public health using talking points that worked for him, he used ones that worked for them. He explains.

Matt Wyant: We were somewhat public health deprived in Pottawattamie County for a number of years. And there was a lot of excitement coming into this, that the county was really going to take some action, and we were going to start really seeing some results happening. Because when we started this out, in 2016, you looked at Robert Woods Foundation, and where our public health rankings were, we were in the bottom 90 of public health outcomes for our residents. And so I had already had a sales pitch basically drummed up about how this was no longer just a public health issue, it was an economic development issue, because for the longest time what I’d known of our foundations were was that their interest laid in economic development. And so if I was really going to get any of those dollars from those foundations, I had to relate it to them in a way that they saw useful to their goals and priorities of their foundations. And it really quickly helped modify their view of us and see that this was something that was worth putting out there. And then when you bring in the citizens behind you to really help echo that across, then I think that was a big help to us.

Deborah Thompson: Public health plays the role of convener, we all know that. We bring people together to ask the questions, “What do we know, what can we do, and who can help?” Well, think of Matt’s fundraising consultant in the same way, but for the private grant world.

Matt Wyant: We as public health, we are looked at as the common ground for various organizations to come in, and we are the conveners, right? We are the ones that bring everybody together, and “let’s talk about these problems and do this”. When I look at on the funding side of it, that’s really what your funding consultant does for you. Your funding consultant becomes a convener, they become the common ground, to where they can help interpret your public health lingo and needs of the community, to how it makes sense to those funding partners, and why it makes sense to be something that is not only funded, but is funded for years to come. And that’s really what your goal of what the health department needs to be. I never wanted to be the health department that was grant based, to where if I lost a grant, then we lost either a service or we lost employees. But I do make sure that the services that are being provided for by grants, that the employees really let the residents know, because I want to keep those expectations there. Let them know that, “Hey, this service is here, thanks to such and such grant, and we’re happy to be able to provide that to you while we have it.” Because there’s one thing in the grant world, it could be cut off at any point in time. That’s another great part, at least with our fundraising, and the consultant that we have and her team, they help really navigate that for us and ensure that we are meeting what the funders want to see. And if we may come to them, and we have that grant that is paying for us to provide something and we maybe want to modify it just a little bit, because we’ve done it for a little bit, and maybe it’s not quite hitting the markers that we want to see, so what if we were to just tweak it somewhat. They help us kind of go back to the funder and explain those pieces to them, and be able to get those approvals to change up what we need. But the funding person is there more on the relationship side of it and just helping you seek out, find, and obtain those funds outside of the state and federal partners. We obtained the grant through the Omaha Women’s Fund, which is a Susie Buffet organization. It’s the first time they reached out over into Iowa, and that was really done through a partnership with our funding consultant and a local foundation, Iowa West Foundation that we have here working with Omaha Women’s Fund and the Sherwood Foundation to be able to do that for us. And so everybody was really excited because it is kind of their first reach out outside of Omaha Douglas County area that they have done, and so we’re very proud of that one. But it does help with… when you get the introduction to those foundations and those foundations talk to one another… We just actually did a meeting because we have a new foundation that’s coming down into our area and they’re out in Minnesota and so they were able to facilitate that meeting between us and that foundation and how they can help us with some of the mental health campaigning that we’re doing right now. I mean, it goes outside of the area. And one thing to help with that for the smaller communities would be, is that hopefully that funding consultant would help like they do with us, and it’s to really foster those partnerships. We have partnered with the other health departments, Douglas County Health Department on the Nebraska side, Sarpy Cass County and formed up a regional health council, which as everybody’s probably seen foundations love partnerships, and they love to be able to fund them in that way. So we came together and formed that relationship and that allowed us to gain another really large grant from the Sherwood Foundation. So your funding consultant will not only be working with you as a health department, they can be possibly working with homeless shelters, food banks, all those other organizations within your jurisdiction and be able to bring those together under an umbrella and apply for a grant that pushes out across for programs that’ll help with everybody in the area.

Deborah Thompson: As Matt said, foundations love to fund partnerships. That’s great because public health loves a good coalition too. Many hands make light work. It takes a village. The more the merrier. Yeah, all those things. Matt discusses a successful partnership he has with his neighbors across the Missouri River in Nebraska.

Matt Wyant: We became a member of Live Well Omaha, and as Live Well Omaha, then Bryan, Douglas County Health Department, Sarpy Cass County Health Department, we’d already somewhat come together and we would partner on a community health needs study for our area. It was really a Douglas County Community Health Needs Assessment that would include a little bit of Pottawattamie County and some Sarpy and Cass County data for everyone. But Douglas County, they are the anchor to it, right? Because they’re the largest population base obviously, and have the largest health department of it all. But they really brought us all together on an even playing field and said, “How can we start utilizing us as the three major health departments?” to gain some real traction in some areas that they had been trying for 20 years, haven’t really seen much on, they really wanted to try something different. And that was really kind of helped what foster up the idea of a regional health board. And that is convened through the Wellbeing partners now, which was formerly Live Well Omaha. And it has members of the Douglas County Health Board on it, Pottawattamie County Health Board on it and Sarpy Cass County Health Boards all come together underneath of that. And then we try to do regional action, instead of – that way all three health departments will agree on “We are going to focus on this area and really try to make some ground in it.” And that just kicked off, probably, later part of 2019. So unfortunately, COVID hit and we kind of lost some traction in that, but all of us have not lost our drive to make sure that the initiative works. But the biggest campaign that we’ll see come out of that right now, is our mental health stigma campaign, and that’s with The Public Good Project out of New York.

Deborah Thompson: A funding consultant sounds great, doesn’t it? But how do you find a good one? And how do you make sure the company you choose isn’t duplicating the efforts of a grants manager that you have on staff? Matt breaks down the logistics and details of bringing a consultant on board, keep listening.

Matt Wyant: You do have to look at some grants and say, “Would we have the ability to manage that grant if we were to obtain it?” Because you don’t every want to fail on a grant. And so there are those conversations that had to be had, “What would be the reporting processes? Could we keep up with those time tracking requirements, all of those different parts of it?” So we just, I guess, we started off possibly – since I already had the funding consultant – our grant person more or less started off as knowing that they weren’t necessarily going to be applying for a lot of grants, just more managing grants, and that the funding consultant was going to really take care of the application process on it, and we just needed to be able to give them the information they needed to submit the applications in timely fashions. We have a service agreement with them, and it is much like any other service agreement with different organizations, right? You have some, depending on who at that company is working on a project for us, we have different hourly rates, and then it’s just paid on an hourly rate manner. And usually our service contract will go up to $10,000 and then anything more than that would have to be specifically approved. But we normally, I would say, stay under that $10,000 for the amount of work that we request to be done. If you are paying your funding consultant more than what you’re bringing in, you have the wrong funding consultant. They should have a proven success rate to be able to show you and the other people that they work with will be able to tell you and provide those stories to say, “Hey, we work with this person at this company, and we get this kind of success out of it.” And I would say it’s one of those easy-to-prove success rates, if they can’t show you the millions of dollars in grants that they have obtained, then you know that, well, maybe this isn’t quite the one I want to work with. And their relationships, you want to look at their network too. They should be talking to you about all the different foundations out there that they work with. Because if you have a funding consultant, and they work with one foundation, well, where’s the other foundations at that are around in there, where are the corporate foundations that they work with, who do they know? And all of them will more than likely, if they have the relationships built there, they’re going to tell you that they’re working with so and so for Mutual Omaha Foundation, they have this person at Peter Kay with that they talk to, and all of those different corporate ones have different goals that they fund, so it all plays for the betterment of your organization. I am a little bit more on the fiscal side of things, I guess, and so when I see… The world that I came from was the planning department, and building department. We have codes and rules and everything that guide us in what we do, it’s very clear cut and dry. On the public health side of things, it is a bit different and to where I had not prepared myself for all of the emotions and personal connections that were on that side of it. So it has helped on that side because of the personal connection aspect, where in the planning and building department you’re not used to having to build those relationships because people just don’t like you. I mean, if you’re on their property, you’re telling them something that they don’t want to hear. But the public health side of it, you have to be the other side to where you want people to like you and you want people to feel passionately about the programs and things that you have going and explain to them the benefits that they see of it.

Deborah Thompson: Over the course of the interview, Matt really covers the pros and cons about public and private grants. For example, he makes sure to mitigate expectations of clients by saying, “We’re happy to serve you while we have the funding.” Because we know that sometimes grants have staying power, but sometimes they end abruptly. His team also waives the administrative burden of the requirements. Sometimes grants are more trouble than they’re worth. Then flexibility, the elusive ability to nimbly respond to emerging issues. In Iowa, we’d lobby the legislature for more flexibility in tobacco funding when I was at the state health department. Thank goodness they granted it because flexibility was key in responding quickly to the vaping deaths that gained national attention over the past few years, the department was able to get educational campaigns out to the public almost immediately. Flexible funding is also helpful for, I don’t know, a pandemic or a derecho. A derecho is a land hurricane for those of you who live outside of Iowa. Yeah, true story, Google it. Matt explains how the funding consultant helps find revenue streams that soften up the sharp edges of a program’s budget. I’m sure you can all agree that a public health budget is a fine quilt, patched and pieced together to cover as much of the population as it can. Think of private grants like the missing pieces, or the finishings that make the structure stronger and more effective. His private consultant listens to the needs of the health department, and then translates it in order to maximize the impact of their work. Matt talks about their importance in making sure that grants respond to his department’s needs, rather than the other way around.

Matt Wyant: So it is a little hard for me to describe that because I think one of the benefits that the funding consultant really helps with is to build that flexibility into the application process, so when it comes across, you are not so locked-in to something being so specific on there, and it does all… As public health professionals, if we were going in there to write a grant, we’d put down very specifically, “This is what we’re accomplishing by this, this and this.” And you almost tighten those confines around yourself, to where if you have that funding consultant, [they] can really come in and help wordsmith that and shape those different requirements out into the grant application, so that way when the meetings are happening with the foundations and the funders, then that’s where all of that can get massaged and ironed out to help provide that flexibility with those fundings. The public-private partnership on that, it’s huge, it’s invaluable on those parts, because they all speak a little bit different language than what we do. And they also have different relationships than we do just by occupational hazard. And so those are really the benefits that you gain from that is the funding consultants are working with all the different foundations, all the different foundations do, on the backside, talk to one another. They know what’s going on out there, they know who’s been successful with grant programs, they know who hasn’t been successful in grant programs. That’s kind of why I’m so fearful of … I don’t ever want to not be successful at a grant program, I want to make sure that we follow through with everything that we tell the different foundations that we’re going to do, because we are bound so tight on those reporting requirements and time-tracking methods that we have. I mean, you could almost miss some of those spreadsheets and things that the state and Feds want from you. I mean, you could hire just two people, depending on the size of your health department. I mean, it could be a person for person almost to sit there and fill it out, because they have the expectations of somebody to go out there and do all this good work for eight hours a day, you almost then have to give them another two hours to sit down and, “Okay, now fill it all out and put it on paper what you did for the day, and try to explain minute by minute what it was.” I mean, it does get arduous on that side.

Deborah Thompson: Matt attributes a lot of his success to relationships. Much of this interview is about how he’s been able to network and build relationships with community funders on behalf of public health. Well, his state representatives and senators are part of the funding picture, too. Keeping them in the loop, as well as the county lobbyists, is all part of the long-game that Matt is astutely aware of.

Matt Wyant: I stay in contact with all of our state representatives, and I always push the fact of public health, where we’re at, where we want to go to, because we have some pretty ambitious goals. I said, “We’ve constantly seen the local public health funding just decreasing and decreasing.” And for us at the beginning, they made it impossible to get, they weren’t going to give it to a new health department. So I really had to utilize our state representatives to say, “Quit moving the bar around, let’s put the bar where it needs to be, and let us reach that point, so we can have those dollars.” But I do see a need of relooking at those because we had those long periods of time to where… One time our local public health funding was $400,000 a year, and then it dropped down to $330,000 a year, and it stayed there for a little while, and then it dropped down again. Now we’re down to where our local public health dollars are, I believe $210,000, and it does make it difficult if… I have to look at it a little differently because we’re a new health department. So if I were going from getting $400,000 and seeing that chopped all the way down into half now, as an established health department, I would struggle. I mean, you lost $200,000 in funding. I mean, that’s a couple of employees, that’s possibly programming that you’re now losing, to where, since we came in at the low end, it would be nice to see those things come up because there are other community efforts that maybe private foundations don’t necessarily need to give us that funding for. And that should be something that really comes from the legislator side to say, “Hey, give us some funding for that.” Yeah, I’ve been very open with our legislators about where we’re at with public health rankings and where we need to be. So I have a relationship with elected officials, I don’t have any issues talking with elected officials and things like that. I think our actions speak louder than words when it comes to my reputation if they felt like… if I was ever concerned that I may speak out too much or something like that, because everything that we’re really saying really is for the betterment of the community. I don’t try to knock the elected officials for not getting us enough funding. I want to work with them to get us more funding and become… So it might just be the newness of it all, to where we’re newer in on it, and we haven’t been through the highs and the lows, but I’m always open to the goodwill of what everybody has to offer. And I just really want to work with them to try to make it a better system for the residents, that’s the main goal.

Deborah Thompson: Matt has heard that other health departments have reached out to a funding consultant, but he doesn’t know of any other departments currently working with one. After listening to what he gains from the investment, we would highly recommend it.

Matt Wyant: Well, I can say that I have heard from our fundraising consultant that they have been reached out to here recently by some other area health departments to work with them on their side of it. And then they do work with our Wellbeing Partners, and… I’m not sure if they started working with Sarpy Cass or not. Douglas County’s so huge, it’s kind of established… they kind of have their own system going and [inaudible 00:25:25] is just a machine of public health, so they just kind of get what they need. If she asks, she tells you that’s what it is, that’s what it is.

Deborah Thompson: In Matt’s interview we discuss the importance of building and maintaining relationships with state legislators. They play a role in funding public health, too. To find out more, we spent some time with a key influencer in Iowa’s legislative budget process. Senator Amanda Ragan hails from Mason City in Cerro Gordo County, Iowa. She’s proudly served her district for 18 years. She’s currently the ranking member of Iowa’s Health and Human Services budget subcommittee, it competes with education for Iowa’s largest budget. She begins her interview discussing some of the challenges for she and her colleagues on this subcommittee, like the fact that of the $2 billion in the budget, nearly the entire amount funds the Iowa Medicaid program. That doesn’t leave a lot left over for the other important issues under their purview like Veterans Affairs, aging, and, yep, public health. I’d imagine this is true for other states. Listen carefully to her insight on how to get the attention of these critical funders, so public health can move up their list of priorities.

Senator Amanda Ragan: So the Health and Human Services budget is massive, and it has a lot of things in it. And I think it’s somewhere around 1.9 billion. That’s huge part of the budget. And a lot of it has Medicaid in it, and a lot determines on what we can do on what the FMAP rate is, which kind of gets in the weeds for most people, but it does have a huge impact. Because that impacts what providers are going to need and what we’re going to need, and have extra money. But we have a lot of programs in there that are serving the most vulnerable people, and so you have to do a balance on all of it. Public health, for example, has a large share of the funding, but Medicaid takes that huge chunk out right away, and now there are many programs that fall into public health as well, so you see that as another piece of it. There are a wide variety of issues that also come up with smoking cessation, and other ways that are helped by funding and then they will impact the agencies that are going to deliver those services as well. So everybody always has their little pet projects that are in there, and you get a lot of advocacy. But it’s a tough committee to say no to, there’s some really important issues that are addressed in funding in that committee. Well, I think, first of all, is this the only source of funding that’s going to be there for that? Whether it’s an agency or whether it’s a program… also their utilization of funds, are they doing everything to make sure that that is utilized to the best, and are there good outcomes from all of it? And we have a lot of personalities when you get to the Health and Human Services budget, so everybody has a different take on whether something’s a good outcome or not. But I think when you see some of the outcomes that come through because of the funding, you see where it gives us more of an impact to, and also whether you want to come back to the table and say, “This is something that really needs to be there.” I know in the negotiations – and we’ve been a part of those things at different times – the house will pass something, the Senate will pass something, then it comes down to the funding. You really have to prioritize because prioritizing is important. Because when something goes off that’s $100,000, that can be a whole program, or it can be enough of a part of a program that really is going to change the way services are delivered. You want quality, and you want to make sure that you’re funding something that it is important, especially when you’re talking health care, to make a difference in people’s lives.

Deborah Thompson: It’s clear Senator Ragan understands the importance of prevention. She expresses concern in this next part for the ever dwindling funds dedicated to prevention programming. This lack of support has an impact, the community needs to be educated and aware of how their everyday behavior impacts their health as individuals, and collectively, the health of their community. This is advocacy, listeners, education is advocacy. But because of all the competing messages about health that’s out there, public health needs to advocate for ourselves as much as we do for the individuals we serve. We need the capacity to educate, we need the funds to buy a bigger bullhorn, so that our nonpartisan evidence-based messaging is what people hear most often.

Senator Amanda Ragan: I think prevention, especially when we’re talking about smoking cessation, and a wide variety of other topics, but that comes to mind right away, because we have tried to put money into that at different times. I’d say it’s decreased lately. And I find that a concerning topic, because we have so many young people that, once you make that choice to start something that’s addictive, I mean, that can change your whole life, and it can also change your struggle in how to alleviate that addiction. So I think education and investment is really good. We’ve seen that with family planning, we’ve seen that in a wide variety of sources that making sure you have well thought-out programs, to go out to the communities and make sure that there is an opportunity for them to be distributed in a thoughtful, intelligent way that resonates with people. And I think prevention can save you… so prevention is pound of cure, or whatever that is, but an ounce of prevention. And then even with immunizations, it’s the education on that, that really needs to be out there. I think especially now, when we’re talking all the COVID-19 issues, people are just trying to grasp to find out what’s the facts. An it used to be something was on a community, whether it was forum or whatever, you would accept that as fact, and now there’s so much disagreement as to what is right and what isn’t right, and it’s, “Oh, so how do you get your information?”

Deborah Thompson: Senator Ragan explains the reciprocity of a relationship with subject matter experts. Facts drive our passion in public health, not our emotions, and she values that. It provides the clarity she needs to make decisions. She encourages subject matter experts like you to proactively come to her with important issues. She also, in return, uses her local public health agency for information when she has questions. Why? Well, because we’re experts, we know our stuff, or at least we know who to ask. So tell me, have you reached out to your elected, listeners? No? Well, here’s a tip, send them your current community health needs assessment, legislators love local data like this, trust me. Ask them if they have some time to chat about it, ask them twice if you don’t hear back from them, do it now. Do it, do it.

Senator Amanda Ragan: I think it goes back to talking about getting the facts. You can get it off the internet, or you can get it off of some crazy other thing or whatever, whatever, or you can go to somebody that has basic understanding and knowledge of the subjects that they’re talking about. And so for me, it’s important when people in healthcare come and talk to me about whatever the issue is, because I think they come to me with knowledge of understanding and educated about the issue. We’ve had issues, and I think you’ve been at some of those, and emotion comes before the education, and I understand how that happens. Your personal life is going to have a huge impact on why you come to understand about issues as well. But that sometimes doesn’t hold as much weight as having the scientific background on certain things. We’re all just laymen coming to the legislature, it is so important to have people that have had the experiences or people that have had the understanding and interaction with people that know how to deal with issues.

Deborah Thompson: We talked with Senator Ragan about the seismic shift of the ACA’s Medicaid expansion. There is no downside to giving more people insurance so they can access affordable health care. Congratulations, by the way, to our friends in Missouri, for their recent expansion victory.

Senator Amanda Ragan: I mean, that expansion was huge, and I don’t think people really understand how that has impacted providers, hospitals – I mean, well, the hospitals are providers – but offices that we’re seeing people that they weren’t getting paid for, and it’s a better health… I mean, we gave flu shots to people that maybe wouldn’t have had them otherwise. Plus, they had the opportunity for health care. Now, that’s the preventative thing, and that’s one of the things we talked about, with the expansion of Medicaid was that prevention piece. And I know that there’s a lot of people that still may not do the prevention like they should. It is really hard for any legislator to be up to speed on all of the Health and Human Services things just because it’s a massive amount, and when you’re doing the budget, it’s not all written out. So some of its in from the last year, and so it’s already in the budget, so they don’t always print everything out. And so learning about that makes it a little more difficult. But one of the things I see is seniors, and just people that are concerned about their health, get all these wacky things on whether it’s Facebook or whatever, or the internet, “Hey, we can solve everything in your life by this one particular medicine and that’ll be the lifesaver”. And you have to have a quality education program or a quality service, instead of some of the fly-by-night things that you just don’t know, and people are gullible. I mean, quick, easy fixes are just sometimes not real.

Deborah Thompson: We asked Senator Ragan for her advice on advocating for public health during politically divisive times. Here’s a hint, have you contacted your legislators yet?

Senator Amanda Ragan: I think it’s great when you have advocacy all across the state, that can agree on something and have your issues that are important. So funding is always important, and that’s not hard to message, because you can say what’s happening, what would be the benefits, and I think you can clearly message that to people. I think having people in local areas contact local legislators still is the best means of making sure that people will listen to you. Your local people have relationships, and they can have an impact, because you know their credibility, and you know that they understand the programs, and they know why services are being delivered. I also think that sometimes they have experienced a lot of changes in funding because of managed care, and that has not been in the news and average people may not know that, but I think most of your legislators are going to be aware of that circumstance. So that would be the second thing is to explain that you’ve had circumstances out there, whether it’s COVID, managed care, just the increase in elderly population, those are maybe three things that would go into why your funding is more necessary. And your first one would be is that you have great programs that you can deliver. I think those are two things with the credibility of the health departments are goo, because they have local delivery of services and people in – and I’m from a very rural area – really like to keep things local. And the public health has been very good about dispersing those funds down to the local individuals and local entities, and that’s really important, so those would be my three. And I also see that the environment is becoming a big piece of the health department’s role in making sure that they can help with whether it’s a business, whether it’s with landowners, with well testing, with any of those things that… People are sort of unaware of all the services. Sometimes just relaying all the services that health departments do is important, because I think, why would you unless you encounter information or need for information, sometimes you don’t realize how much is out there.

Deborah Thompson: Remember the value of your services, what you offer to the community that no one else does. You are a credible resource to turn to and you connect people. Be sure to let legislators know your services are valuable to their constituents. What’s valuable to their voters are valuable to them, too.

Senator Amanda Ragan: They really have never been in a situation where they’ve been very independent and don’t want to look for resources. Going to the health department, they’re very good at coordinating that for you, making sure you get to the right services. If they can’t, they’re just a really good resource that can tell you who can. And they work so well with the local agencies, as well as the providers here, at least that’s what’s been my experience in my counties. They’re all very good at working with all the other agencies that provide services. They’re one of the groups that are involved in when you are talking, whether it’s a flood, whether it’s a tornado, they’re part of the emergency management team. And so there’s such a wide variety of services, that’s why it’s important to relay that to legislators, so we know, “Yeah, we should be funding these people.”

Deborah Thompson: Senator Ragan is truly a public health champion, more of those please. Thank you, Senator, for sharing your expertise and advice with us, I’m sure many will take it to heart. Next up is Dennis Kriesel. Dennis is the executive director of the Kansas Association of Local Health Departments. This nonprofit association’s dedicated to strengthening local health departments in Kansas, and all 100 of the states local departments are members. Love the unity here. Recently, they scored a funding victory. Yep, after 30 years, they got an increase. Well, until COVID hit, that is. Dennis explains how they achieved this public health win, even if it was put on hold for a year.

Dennis Kriesel: My name is Dennis Kriesel, I’m the executive director of the Kansas Association of Local Health Departments, or commonly referred to as KALHD. My background in public health, actually, is I started as a public health policy fellow out of college with the Kansas Association of Counties, that was back in 2002.

Deborah Thompson: Why should we give you more money? This is literally the million dollar question. What they’re really asking is, “How do I explain this investment to my constituents, the people who hold me accountable at the polls? What is the return on investment for the taxpayers?” It’s a fair question. And for public healthers, coming up with a good answer is something that we really struggle with. That’s one barrier Dennis discusses. This, and oh, the barrier of not even asking for additional funds. This barrier is tragically common. Not asking makes it pretty easy for legislators to do nothing. Listen to his advice on overcoming these barriers.

Dennis Kriesel: I think the biggest issue is probably that the legislature or the commissioners or whoever you’re talking to about the funding, don’t know what they’re getting if they give you more. What are you buying? What gain do you have? So I think part of the issue is, historically, public health departments haven’t gone with any sort of messaging, there’s a communication gap there of being able to explain why should we give you more money to whomever, whatever group you’re approaching about that. So I’d say that’s probably what I think the number one issue is, plus there’s also a propensity, at least here in Kansas, to not ask. That’s what it looked like to me when I came in was – there was a whole lot of not asking going on. So if you’re thinking that someone’s going to go and say, “Oh, public health, that’s important, I should give you more funding,” but you didn’t ask for it, there are so many competing interests, that is very wishful thinking. Public health needs to approach whatever entity it seeks to pursue funding from, with, ideally, an amount that you have in mind, and an argument as to why you should have it. And that argument will include what you plan to do with the money, obviously. So if your plan is that you want to do more work on social determinants of health, but there’s nothing that pays for that currently, and you have an idea, maybe… it doesn’t have to be as broad as to say, social determinants, it could be, “We want to specifically address this area on housing,” or, “We’ve got an issue in our county with people being able to get to the doctor’s office because they lack transportation. So let’s talk about putting something together on bussing in the city. And here is a proposal that we got, here’s where we think we could start a bus route with three stops. And this is how much it’s going to be. So here’s our ask, and this is what we’re going to use to measure to show that we’re actually meeting our deliverable.” And then you have something that you’re selling, you’re selling this idea to them to see if… They’re almost like a granter in a way, in fact, you can do the same approach with a grant. So you’re going out and you’re saying to these policymakers, in the examples I’m thinking of, with this argument about what you want to do with it, what you hope to achieve if you’re able to actually execute on those deliverables, and then that’s why you need the amount of money you’re asking for. And then hopefully, either they completely agree and give you all the money, or more likely, they’ll ask questions, maybe they’ll try and haggle that down and say, “Well, what could you do if I could only give you half of what you asked for? Could you still do something? Could you still help?” And you need to be realistic with that, too. If a project falls apart… All projects have to fall apart at some point where the money is too small. And in some cases, I would argue, it’s actually worse to accept that than to accept nothing because you won’t be able to show any deliverable, and then all you have presented is that you are a failure. You’ve gone out, you’ve obtained money, and you didn’t do anything meaningful with it. So you always want to be able to ask for and get at least enough to accomplish something, even if it’s not as ambitious as your initial plan was.

Deborah Thompson: The skill sets needed to navigate the legislator process are also scant in local public health agencies in Kansas, although it does sound familiar to the plight in other states too. Strong professional associations fill this gap. A plug here for all of the state associations out there, please join yours. They all operate on economies of scale, like membership dues. Okay, Dennis explains what his organization did to support their members, and the goal to get increased funding after a 30-year wait.

Dennis Kriesel: People who work in public health weren’t trained in policy development and doing these cost proposals. In fact, a lot of our local health department directors in Kansas aren’t really formally trained administrators in general, a lot of them are nurses who have become public health administrators because they live in very rural counties, these health departments are being filled by their county commissions, the county commissioners need nurses because there’s a statutory obligation to do immunizations for school-required vaccine. And they’re kind of doing it two bird, one stone thing, where it’s like, “Well, the RN’s the best trained person at the health department, let’s make them be the administrator at the same time.” So you end up with people that were trained on how to be nurses, but weren’t trained about how do you go forth, build budgets and ask elected officials for funding. And that gets even more complicated when we’re talking about the state level. If we’re talking state resources, what’s that process? I mean, most entities in Kansas, if they’re pursuing funding from the legislature, they have lobbyists for that stuff. You don’t go in off the street and ask for money. I mean, there’s a process, it’s the people’s chambers that you’re allowed to. But it’s a nebulous process that almost no one in public health was trained to do. So I think that feeds into that fear and there’s this sort of the sense of, “Well, we’re not political creatures, we don’t know how to go and do that aspect of it.” So that’s where organizations like KALHD can come into play, as well. We are a nonprofit professional association, we are legally entitled to do limited lobbying, not just advocacy, but actually asking for policies, asking for funding included. That’s something that we did as an organization in 2020. And so that’s the way you can go about tackling that. So that sort of feeds into your second question about how did we do an ask? So here in Kansas, one of the things that I looked at when I came in to this organization in 2019 was, what are your funding sources currently? And at the state level, there’s one primary source of funding, we generalize it and call it the state formula. What’s nice about the state formula is it’s highly discretionary, it can be used for essentially any public health purpose that you want. The problem with the state formula funding is that it has remained at the same level of $2.22 million since 1992. So it hasn’t been updated, even though we have obviously had inflation, and we’ve also experienced population increase since almost, 29 years ago now. So because that money, ostensibly, is to pay for all of these mandates that the state has, we have a decentralized health system, but the state makes the rules on what you have to do, things like those vaccinations for the school kids, maybe school sanitary inspections are in the statutes, a whole lot of environmental stuff is in the… There are a variety of things that the state expects to be done, that the local governments are to take care of. So those things aren’t individually funded, in most cases, line by line in the state budget, I believe. It predates me, I was in middle school when that funding was updated in ’92. But that funding, I am assuming, is the legislature’s response to saying, “This is how this is not an unfunded mandate. Here’s $2.2 million to pay for all of that stuff across the state.” Okay, fair enough, except you didn’t keep up with inflation. So that was our argument in 2020. So I went to the legislature, I got my membership to write letters to those that were on appropriations committees, on public health committees, on the subcommittees that deal with budgets related to public health, to sort of lay the groundwork. And the way I got them to get over that fear is I wrote them, I drafted the templates and said, “Here is what I would do if I were you. Modify it as you see fit. If you’re uncomfortable sending it, you don’t have to send it. But if you want to help, I would send something like this.” When it came time to do the testimonies, same thing. I gave them templates on testimony. We had a foundation that funded us to develop template examples on how to do testimony, under advocacy. Here, “This is how testimony looks.” And I gave them examples based off of real bills and real proposals, and said, “By the way, if you want to turn this advocacy into lobbying, you can do so. You have to be willing to fill it in and sign your name to it. And I will turn it in for you, I’ll take care of all of the legislative hurdles. You don’t have to worry about how many copies, you don’t have to worry about the deadlines. All you have to do is get it to me by the date I say, and I will take care of it for you.” And so we went into the Kansas legislature with a $1.9 million ask of an increase to move that 2.2 million to $4.1 million. And throughout that legislative process, we actually did ultimately get a $900,000 increase approved and signed by the governor in the budget. And then, thanks to COVID, lost it all, because an allotment process kicked in and stripped out all of those increases in the state fiscal year budget because the government-shutdown meant that the tax projections are such that we can no longer confidently know that the state wouldn’t run out of money. So we get to do it all over again. Because we couldn’t get the governor to ask for the money for us, which was what I wanted to do. So the only way to do it was to try and do this grassroots thing where I can do, as the lobbyist for public health, for local health departments, I can go and do the public speaking testimony. But the strategy relied on trying to get health departments to at least turn in written testimony. And I knew we had done a good job when the Senate Ways and Means subcommittee that deals with social services budget, had their hearing. And before I even got to speak, I was walking in and there was another lobbyist who looked, and outside of the room on the table was all the testimony to talk about issues related to those budgets. And he didn’t look at me, I just saw him at the table, and I heard him say, “Wow, local health departments have a lot of testimony here.” I’m like, “Yeah, because we’re winners. That’s why.” We swarmed them with volume. I had, representing local health at that table, I think we had over a dozen health departments and county commissions that turned in testimony saying this money was important to them. And that was the sale, it wasn’t me. Me coming and speaking, it’s just like, “I’m spelling out the ask. It’s going to be state general fund. Here’s why we want it. Here’s all…” Most of those senators had already made up their mind that they were going to back something just because they knew who those departments were. I most encouraged those who had senators from their counties on that committee to turn stuff in. And that was a key part of the strategy. Even as busy as they were – and this was before COVID was taking up all their time – we had all this stuff resolved by mid-March. But they were able to just go in and you could, in under one minute, take a template and turn it into your own thing where all you had to do is change a few categories, throw it on your letterhead and put your signature on it. And removing that barrier of saying… I think it’s easy to forget what a barrier it is for someone who doesn’t do this all the time, is trying to run a health department, maybe work their health clinic, and someone comes in and says, “Oh, hey, can you write me six paragraphs supporting this funding ask?” Which they might not even fully understand the details of the ask because they didn’t write the ask, I did. So doing it this way just removed a lot of barriers. And that was why we did the project with the Kansas Health Foundation was, I wondered if there were templates, if it would make a difference. I’m convinced that it would, after seeing the just the sheer amount of results of people that were willing to fill in templates on all sorts of issues, I was like, “This gets so much more engagement than just saying, ‘Hey, this is important, do you want to turn in testimony, we’ll help you out?'” The more vague it is, there’s a degree of hand-holding that if you’re willing to hold the hand, they’ll walk the path with you. But if you let go of the hand, it’s just there’s so many other things that are important for them to do. You’re really asking a lot if you’re not doing most of the mundane work for them.

Deborah Thompson: Site visits, Dennis talks about the value of inviting electeds to tour your health department. I couldn’t agree more. I toured several local health departments when I was with the state, each time was memorable. One visit still stands out, the health administrator had me shadow several of her staff. I was whisked away to a home visit, a facility visit, an immunization clinic and their WIC clinic, I learned so much about public health in action. Not only that, my appreciation for the profession was unshakeable after that. More electeds need to see what you all do, public healthers, so they can appreciate you, and you deserve it.

Dennis Kriesel: Invite them to take a tour of the health department. That was the very first step we did. And I remember I had a few emails, or follow-ups, for health departments, but one of them in particular, she… this is paraphrased, but it’s close to what she said, she goes, “Holy crap, Dennis, I wrote to this legislator, and he’s going to come visit. I don’t know what to do. He’s going to come visit.” I’m like, “It’s good. This is a good thing.” She’s like, “I didn’t think he’d say yes, I didn’t think he’d respond.” I’m like, “You are his constituent. A lot of them won’t respond, that’s true. But a lot of them actually do care. They actually went into this, because they want to make a difference. So this is very good news.” It just, “I don’t know what to do.” “Just show them what you do professionally, and say why it’s important.” And that’s it. That’s all you need. All we’re trying to do right now is get you, as an entity, and public health as a field, on his radar. So that when I come knocking and saying, “This hasn’t been changed for 28 years, can we have a little bit more money? You didn’t reduce any of our workload in the past 28 years.” They can go, “Yeah, that makes sense. Yeah, maybe we should update the money maybe every three decades I don’t know, maybe?” And so I think that helped. I mean, again, while we did not get allocated the full amount we wanted, I didn’t think we’d get anything the first year coming in, and the reaction was a lot better than I thought it was.

Deborah Thompson: It’s very common practice to have the governor make his or her budget recommendations to the legislature before they begin their appropriations process. If the governor and the majority party have the same political affiliation, then having a united front on the budget is even more important. So it’s a good goal to have your appropriation included in a governor’s budget right from the start. But, as Dennis explains, it’s not impossible to overcome the setback if it’s not included, because you’re still a part of a constituency back home. That’s the main difference for legislators and why it’s critical that you invest in these relationships.

Dennis Kriesel: Why should we give them money, the governor didn’t even ask for it? That was the biggest, and I was like, “This is what… I’m telling you, KDHE…” And I mean, behind the scenes, the state was very supportive of us. But publicly, they couldn’t take a position on the bill, because the governor’s position was, “No increases and asks except Medicaid expansion was a priority.” So that was the one area. But I knew this was going to be the problem because the moment I’m there, and I’m saying, “I want 1.9 million,” and the governor didn’t say we needed 1.9 million, that allowed fiscal conservatives to latch on to that even though the governor is a Democrat, and say, “Well, not even the governor is saying that they need 1.9 million. So why should we listen to you?” And I mean, there are only so many nice ways I can say, “Well, the governor doesn’t know a thing about the state formula. This is to go to county health departments, she’s not concerned with that.” I mean, that’s out of sight, out of mind. We actually had legislators and again, maybe there were some that were outreached by my membership, but when the full House Appropriations was meeting to discuss what their Social Services Budget Committee had come up with, which was who I verbally had testified to, those appropriations people were like – they weren’t all on that other committee – so they’re seeing this proposal like, “Yeah, the governor didn’t ask for it. Why are we doing this? There’s no point.” And they wanted to table it and push it off to a conference committee, which wasn’t the end of the world, but I was like, “No, I wish they wouldn’t do that.” There actually was a legislator in that hearing, who also was not in sub- in the prior committees… It’s not really subcommittee, I keep almost calling it that. And he was just like, “This is ridiculous. Why are you guys even debating this? It’s been 28 years, what’s wrong with us? Why would we sit here and say that they somehow can still do what they did with 1992 dollars, and you want to put this into a conference committee when this is so obvious? Why are we wasting our time? We’re here to be decision makers, let’s make a decision.” And they did not table it and push it into conference, they approved it. And I think it was a little bit of shaming from one of their own members that helped encourage them to finally just, instead of punting, which is what they wanted to do, just be like, “Fine.” I mean, it was nine… Well, in that case, it was $1.9 million, it really wasn’t… We’re really talking very small dollar amounts, compared to a lot of the other social service asks that were approved, my piece was small. So that helped too, it not being a huge dollar amount. The actual challenges … most of the county health departments were doing things like clinic work that actually made them money that they used to subsidize their budgets, they can’t run their clinics anymore, they’re shut down because they’re worried about COVID infections amongst their WIC population. So we have lost a lot of outside discretionary dollars, because all we can do is COVID, and we’re trying to protect the clients. So those are the arguments I think we’ll end up making. If the governor has it in her recommended budget, though, it will make life so much easier, because the recommended budget is what the legislature will consider. They’ll see the base budget and the governor’s recommendations, and someone would basically have to argue against her recommendation, instead of me having come in and argue to add something on top of it. And clearly our strategy of sit for 28 years and not ask for money, as near as anyone I was able to check with has said, KALHD as an organization has never asked for a state formula increase until I did this year. That isn’t going to work, obviously, because you didn’t get anything in the subsequent 28 years, so we have to do something differently.

Deborah Thompson: Wow, listeners, what great advice preached by three incredibly experienced individuals. Now we know who to talk to about increasing your budgets and some strategies for how to go about it. Now it’s time for you to diversify your funds, lobby influencers and legislators and make your asks. You are worth the investment, public healthers. Tell funders that you are the only sector who diagnosis community health problems and convenes people who can help with solutions, so that problems are prevented for all people in your community. For more information on what to say, visit phrases.org for helpful messaging tips, that’s P-H-R-A-S-E-S.org. It’s a public health messaging project funded by the de Beaumont Foundation. Thank you to all of today’s guests who gave their time to this episode, Matt Wyant, Senator Amanda Ragan, and Dennis Kriesel. Thank you, thank you. And be sure to check out the other episodes of Share Public Health, especially the advocacy episodes. I’m Deborah Thompson, thanks for listening.

Thank you for tuning into this episode of Share Public Health. Thank you to Sonja Armbruster, Brandon Grimm, Jeneane Moody, Hannah Shultz and Kristin Wilson for helping to plan and produce the series. Thank you to Melissa Richlen for audio production and support. This podcast is supported by a grant from the Health Resources and Services Administration. A transcript and evaluation for this episode is available at mphtc.org and in the podcast notes.

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