The COVID-19 pandemic shined a light on how state and local health systems in the United States, burdened with public health responsibility, have been underresourced for decades1 and not fully equipped to meet the public health challenges they face. Despite the tireless efforts of public health workers during the early days of the pandemic, their struggle to keep up uncovered deficiencies in resources and preparedness. But the pandemic also unlocked substantial federal funding to help state and local governments reset and refocus their efforts to create more resilient and equitable public health systems. With this support expiring in 2027,2 leaders have a limited window of time to take full advantage of this opportunity.
Opportunities to improve public health are numerous. As of 2022, about 42,000 adults and 300 children die annually from vaccine-preventable diseases.3 Up to 60 percent of maternal deaths are preventable.4 And more than two-thirds of all deaths in the United States are caused by chronic diseases such as diabetes and heart disease.5
Billions of dollars unlocked by federal relief laws, passed in response to the COVID-19 pandemic, now present state and local public health agencies with the ability to adopt innovative tools and policies and propel performance improvement to heal the ailing US public health apparatus. As time runs short to apply for these dollars, it is critical that state and local governments take this opportunity to advance solutions that are tailored to local contexts while building on lessons learned from across the nation and around the globe. In this article, we outline four potential steps that state and local public health agencies can take to change the health trajectories of their populations. Moreover, to help leaders and administrators zero in on interventions, and to help improve the well-being and longevity of the people they serve, McKinsey has created the United States of Health Dashboard, a data visualization tool that enables users to explore the impact of disease and ill health in individual states.
An opportunity for better health outcomes
COVID-19 tested and changed how public health efforts are implemented. The rapid spread of the virus required policy makers and public health officials to quickly mobilize resources and carry out proven interventions to slow transmission and, ultimately, save lives.
The pandemic also forged new partnerships—among state agencies, commercial labs, hospitals, community-based organizations, the federal government, and others—that can serve as models for responding to future public health needs. Meanwhile, the crisis confirmed the importance of the integration of data systems across stakeholder groups and jump-started the Data Modernization Initiative of the Centers for Disease Control and Prevention (CDC). This effort helped build capacity for frontline public health programs and gave rise to new digital infrastructure platforms that will support public health administration for years to come.
Large injections of funding made these innovations possible: federal spending on public health during the pandemic topped $37 billion (Exhibit 1). In all, state and local health departments have received 50 to 100 times more funding in recent years than they did before the pandemic.6 Millions in philanthropic donations, mostly from independent foundations and corporations, have also flowed to local communities, according to the Center for Disaster Philanthropy.7
However, spending of this magnitude is unlikely to continue beyond 2027, when current federal support to state and local governments for public health expires—which means state and local administrators need to act now to improve health outcomes in high-priority categories of public health.
Disparities between funding and performance
The opportunity to address public health challenges rests with individual states, counties, and cities. In 2018, for example, state and local governments spent nearly seven times more than the federal government on public health activities ($81.5 billion versus $12 billion).8 In addition, prior to the pandemic, public health funding from the CDC had been declining, dropping from $8.6 billion in 2010 to $7.9 billion in 2021 (after adjustment for inflation).9
Moreover, public health efforts are largely decentralized, based on a loose patchwork of policies and programs, and unevenly distributed across the country. These efforts see varying, sometimes inadequate, results, and they affect population groups inequitably.10 In our comparison of per capita public health spending and disease burden, we find little to no correlation between the two variables (Exhibit 2).11
For example, two states spent roughly the same amount on public health per capita in 2019, yet one state’s disease burden was 50 percent greater than that of the other. Although disease burden is heavily affected by other variables, including age distribution, poverty levels, and access to care, the disparity between spending and outcomes demonstrates an opportunity for state and local agencies to ensure that spending focuses on the evidence-based interventions and innovative programs that have the greatest impact.
A pathway to confronting public health challenges
To capitalize on this moment and significantly improve public health outcomes, state and local governments could prioritize the most important policy areas in public health, scaling up efforts that have the most significant impact while sunsetting those that do not.
In reorganizing their public health efforts, states and municipalities could consider how five areas of public health—chronic disease, communicable disease, maternal and neonatal health, behavioral health, and environmental health—affect their communities and what types of programming are needed in these areas. For example, they might consider how chronic disease risk factors are managed and how public health agencies can improve prevention. How could lessons learned from the COVID-19 pandemic be scaled? What are the most common birth complications, and how could they be avoided? How have behavioral health challenges changed in recent years, and how could access to high-quality support be improved? Finally, how can states address environmental factors like air and water quality, which often underpin health and well-being?
In addition to examining these programmatic areas, states and local governments can investigate the maturity of several cross-cutting capabilities that will affect their ability to improve public health (Exhibit 3). These include organization design, talent, and organizational health; IT infrastructure and data and analytics; preparedness for and responses to health hazards and emergencies; communications, partnerships, and community engagement; financial efficiency and operations; and governance and cross-agency collaboration (see sidebar, “Foundational capabilities for public health improvement”).
A diagnostic process that focuses on these primary programmatic areas and cross-cutting capabilities can set the stage for the comprehensive acceleration of a state or local agency’s agenda for public health reform. This process is best implemented in steps, which include aligning with goals, prioritizing specific interventions and approaches, facilitating collaboration for designing and scaling solutions, and establishing sustainable mechanisms for funding. These steps could be taken in conjunction with various partners, both within and outside of the government, and with the community’s help when it comes to setting goals and designing and implementing solutions.
1. Align stakeholders on specific and measurable five- to ten-year goals in key programmatic areas for public health
Goals for public health improvements could be informed by a robust fact base that includes a comparison of state and local data over time or comparisons with neighboring or similar states. The goals could focus on equity, with an examination of outcomes for specific populations and communities and an analysis of specific public health issues such as depression, diabetes, and maternal deaths. The goals could be drafted in collaboration with community partners and other stakeholders. The United States of Health Dashboard offers detailed insights on the disease burden in individual states.
To understand what comparing states’ disease burdens might look like, let’s explore a single, anonymized state, “State X.” In Exhibit 4, we compare its disability-adjusted life years (DALYs)12 per 100,000 people with the average of all US states in the five programmatic areas as well as with one neighboring state. These comparisons reveal that State X has a greater-than-average need to improve its maternal and neonatal health and communicable disease outcomes. A side-by-side comparison of State X and a neighboring state reveals that priorities in each programmatic area may differ. For example, State X has a higher burden of communicable respiratory disorders, while its neighboring state has a significantly higher per capita burden of HIV and AIDS. Given this information, state leaders might consider setting short- and long-term goals in these two programmatic areas (communicable respiratory disorders and HIV/AIDS), along with identifying leading and lagging indicators for tracking their progress toward reaching the goals.
2. Prioritize and fund interventions and approaches that support goals for public health outcomes
While prioritizing specific efforts, state and local public health leaders may need to rebalance other factors, including the following:
- scaling evidence-based interventions versus providing dedicated support for promising practices in local communities or specific vulnerable populations
- focusing on efforts that address immediate needs versus making long-term investments to redesign existing systems
- supporting specific programmatic efforts versus building public health foundational capabilities and infrastructure for the future
An in-depth understanding of contributing risk, such as environmental and behavioral factors, with an emphasis on factors that local public health agencies can address could help local agencies determine what to prioritize and where to act. Potential interventions could include those focused on data collection and analysis, technological infrastructure, policy development, public health education and awareness, or improved service and care delivery.
For example, for a state to address its below-average maternal and neonatal health outcomes, public health leaders could consider building data and analytics functionalities to track birth defects and identify maternal populations at high risk. They could also encourage policies that expand insurance coverage of smoking-cessation services for pregnant individuals, including counseling services and pharmacotherapy.
3. Facilitate cross-agency and cross-sector collaboration to design and implement prioritized efforts
Designing and implementing interventions requires consistent cross-sector and cross-agency partnerships that public health agencies could facilitate. Public health agencies could consider forming partnerships with adjacent agencies (such as Medicaid or the Department of Labor), local governments, schools and universities, community organizations, healthcare providers, employers, and community leaders.
For example, to carry out maternal and neonatal health interventions, State X could enlist community stakeholders such as churches, schools, libraries, and soup kitchens to help identify individuals in the state who are at risk for pregnancy complications. Public health leaders could also partner with Medicaid and other health insurance payers to expand their coverage of smoking-cessation services.
4. Establish sustainable funding mechanisms and performance infrastructure to ensure long-term improvement in public health outcomes
While one-time funding injections may help to launch innovative efforts and create a foundation for future success, state and local governments could consider establishing sustainable funding mechanisms for public health efforts, including those focused on prevention and well-being. Sustainable funding requires the strategic use of federal dollars and cross-agency collaboration (for example, with Medicaid or the Department of Education) to address cross-cutting programmatic needs.
In addition, state and local public health agencies may want to ensure accountability and transparency by monitoring the progress toward goals and supporting rapid decision making related to state and local public health efforts.
With significant public funding still available for the next few years, state and local governments are uniquely positioned to build on recent progress and reengineer their public health agendas and operations. By selecting strategic goals and interventions, forming critical partnerships, and ensuring sustainable funding for these efforts, states and local agencies could potentially alter the health trajectories of their populations for good.
