The Honorable Aaron M. Michlewitz
The Honorable Michael J. Rodrigues
The Honorable Daniel J. Hunt
The Honorable Cindy F. Friedman
The Honorable Todd M. Smola
The Honorable Patrick M. O’Connor

Delivered Electronically

Dear Chair Michlewitz, Chair Rodrigues, and Distinguished Members of the COVID Recovery Bill Conference Committee,

As a follow up to our letter yesterday which outlined municipal priorities on a range of issues in the COVID Recovery bills, we write today to follow up on the specific issue of transforming local and regional boards of public health. The Special Commission on Local and Regional Public Health’s report titled “Blueprint for Public Health Excellence (“Blueprint”) offers a realistic, two-step process to reform the local public health system (page 30). The first step was to transition local boards of health into compliance with existing statutes and regulations. The second was to help local boards of health build capacity in readiness to meet a minimum set of standards, known as the Foundational Public Health Services.

As you know, Section 40 in S. 2580 would impose spending mandates on local and regional public health departments. While we wholeheartedly support the intent of the provision, which is to strengthen capacity, collaboration and investment in local and regional public health departments, we strongly urge you to not include unfunded mandate language and follow the guidance and recommendations from the Blueprint in order to set local and regional boards of public health up for success:

The Commission acknowledged deep fiscal challenges locally, and affirmed the reality that municipalities cannot increase their municipal spending on public health, because they rely almost exclusively on local property taxes, which are capped by Proposition 2½:

“Unlike most other states, in Massachusetts, local public health departments rely almost exclusively on local property taxes and fees for funding. By all accounts, many or most are already straining to provide necessary services. System-wide changes such as grants programs, technology, training, and technical assistance will clearly benefit individual cities and towns, but while municipalities have some incentive to financially support such efforts, the reality is they cannot. These changes will also, however, improve state-level outcomes, reducing health costs overall and helping to create a healthy workforce, indirectly bolstering the economy—a significant public good. It is therefore appropriate that the Commonwealth consider providing funding to modernize the local public health system so it can meet its existing mandates and the expanded expectations of the 21st century.” (page 66)

The Commission recognized that while a few municipalities may have the resources to implement the new standards, most do not:

“Local public health budgets in Massachusetts vary wildly and are almost always subject to the many and competing demands of other municipal departments. Bigger and wealthier municipalities may spend up to $25 per capita annually. But the half of all Massachusetts health departments that represent towns of less than 10,000 residents, gateway cities, and municipalities with funding shortfalls face significant challenges with resources.” (page 67)

The Commission’s own report identifies the massive new cost of implementing the new standards (up to $140.5 million a year in new mandated costs, using the Commission’s own report), and says that further study is necessary before codifying the standards:

“The Public Health Leadership Forum found that $32 per person was needed in 2018 to support a FPHS local health department. In Massachusetts, once health departments are meeting existing standards, an additional investment, estimated at between $15 and $20 per capita per year based on the national study, will be needed to help lift their performance from that baseline to allow them to achieve the foundational public health services (FPHS). Further study and analysis will be needed to better estimate Massachusetts’ FPHS funding needs. DPH calculates that local health departments currently only fulfill three or four of 10 essential public health services, although these are somewhat different from FPHS. At some point in the future, the federal government, most likely through the U.S. Department of Health and Human Services, may provide grants directly to local health departments, or through state health departments to local health departments, to upgrade their standards and improve their capacity to protect residents.” (pages 69-70)

The Commission’s own report says it would be a mistake to mandate Foundational Public Health Service standards without first building the capacity to do so:

“The health of Massachusetts depends on the complex interplay and strong partnerships among state agencies, the local public health system, and the healthcare system. Boards of health are the “boots on the ground” for each town and city and a beacon that often acts as the first alert to a public health problem or crisis. Yet many local health departments in Massachusetts are in a perpetual bind: stagnant or diminished resources and ever-increasing state and federal mandates. They may try to do more with less, but it is an unsustainable solution. To push them to upgrade to Foundational Public Health Services (FPHS)—without first developing the readiness and capacity to do so— will just intensify the crisis for these struggling cities and towns—and widen the gap between them and the small number of well-funded and supported health departments that will be able to implement the new standards.” (page 71)

The Blueprint report recommended voluntary, not mandated, standards as the next step:

“Because the health departments are the critical actors in modernizing the system, the Commission recommended considering the voluntary adoption of a minimum package of public health services (FPHS). This would encourage cross-jurisdictional sharing, raise data standards, better prepare the workforce, and help each local health department advance towards accreditation. It was beyond the scope of this phase of the project, however, to assess the feasibility of doing so and to estimate the resources needed to get the system to meet the national benchmark.” (page 73)

When the Blueprint was released, one of the key findings was that most local boards of health were unable to keep up with a growing list of duties. Of course, this finding was pre-pandemic. Their duties and importance have now grown exponentially. In an era of global pandemics, we understand the desirability of local public health performance standards more than ever. However, without a clear analysis of the costs associated with such mandated minimum performance standards, and no identified dedicated and permanent state funding source, the responsibility to support these mandates would be a new burden placed on the backs of cities and towns as a significant new unfunded mandate.

The wish to fast-track the transformation of local boards of health, by mandating that they meet a minimum set of performance standards now, is understandable following the recent public health emergency. We share this desire, but acknowledge the Blueprint’s warning that, “to push them to upgrade to Foundational Public Health Services (FPHS) – without first developing the readiness and capacity to do so – will just intensify the crisis for these struggling cities and towns – and widen the gap between them and the small number of well-funded and supported health departments that will be able to implement the new standards” (page 71). We know that this is not the Legislature’s intent and wish to work with you to make sure this does not happen.

Additionally, a study has not yet been conducted regarding the cost necessary for municipalities in Massachusetts to meet existing standards, nor is there any analysis of what it would take for them to achieve the new foundational public health service standards. The data included in the Blueprint indicate some municipalities are providing such a very basic level of services that the cost to bring municipalities up to meet these standards has the potential to be enormous. For example, over 70% of local public health departments do not have enough staff to comply with current statutory and regulatory duties, and 80% of local public health department representatives agreed that they do not have the capacity to provide the most essential public health services to their citizens (page 33). We strongly support the one-time funding of $250 million included in S. 2580 to support local and regional boards of public health, particularly the $95 million in grants to local health departments, and see that investment as a major first step forward. However, without an ongoing state-funding source, the overwhelming majority of municipalities would not be able to meet the mandates of these bills on their own.

Local health budgets vary widely by municipality, and are subject to the competing demands of other municipal departments and funding needs. If these bills pass, municipalities would be mandated to devote an unknown amount of additional funds each year in order to meet these mandates. Because local revenues are capped by Proposition 2½, cities and towns cannot absorb new funding mandates without reducing other expenditures on essential public safety, education or other critical services. Further, without a dedicated source of state funding, it would be unclear from year to year if necessary funding from the state would be available to match contributions from municipalities. Expanding department staffing capacity to meet any minimum standards would require long-range goal-setting and planning that would only work if dedicated state funds can be guaranteed. Short-staffed departments cannot hire the permanent professional employees necessary to meet and maintain minimum performance standards without knowing if reliable state assistance will be provided from year to year to maintain those hires. Moreover, the non-public-health aspects of many municipal operating budgets are already facing severe shortfalls. The mandates in this bill would worsen an already dire fiscal situation, and force further budget cuts in other important departments. While municipal budgets have received a temporary and welcome boost of federal stimulus funding, municipal leaders are mindful that this is one-time money, making it difficult to create staff positions that cannot be sustained when the funding is gone.

The MMA supports the vision of a 21st century model for local boards of health, and agrees that this is a vital aspirational goal to achieve for the health and safety of all residents of the Commonwealth. However, the language in its current form in S. 2580 omits necessary steps detailed in the comprehensive Blueprint, and would have the unfortunate impact of overburdening local boards of health and harming municipal finances, instead of improving capacity and finances at such a critical time.

We welcome the opportunity to engage on this topic of improving local and regional public health departments, and the funding mechanisms required to do so. Please include municipal leaders in a decision-making process that would have far-reaching financial implications for every city and town before codifying this mandate in state law.

The partnership between state and municipal leaders was critical during the public health emergency, and it remains critical as we take steps to improve the delivery of services. Thank you for your attention to this important matter. If you have any questions, please do not hesitate to have your office contact me or MMA Senior Legislative Analyst Jackie Lavender Bird at 617-426-7272, ext. 123, or at any time.


Geoffrey C. Beckwith
MMA Executive Director & CEO

Cc: The Honorable Ronald J. Mariano, Speaker of the House
The Honorable Karen E. Spilka, Senate President