Research and Translation

Dr. Heather Krasna is a leading voice in the effort to understand why our nation’s local, state, tribal and territorial government health departments have experienced a staff shortage for decades, a shortage that worsened during the Covid-19 pandemic. While there have been recent federal investments in government health departments, especially via the Public Health Infrastructure Grant (PHIG), health departments experience a range of barriers to bolstering their workforce. One major underlying problem is the lack of clear data on how many staff work in health departments. The US Department of Labor Bureau of Labor Statistics (BLS) uses workforce surveys which do not gather data in enough detail to answer simple questions like “how many nurses work in local health departments?” Improvements to the coding tools used by BLS could improve the ability for policymakers to answer the questions that would reveal the size of the workforce shortages and advocate for increased funding. The short-term, “crisis and neglect” funding pattern in public health is another challenge—it is difficult to plan programs or build a sustainable workforce with short-term funding.

Other underlying challenges include complex hiring rules and procedures, as well as slow hiring timelines, which can make it difficult for job applicants to be hired into permanent positions in health departments. An equally difficult issue is the disparity in salaries for government workers overall, and difficulty adjusting the salaries to match market rates. Advocacy to support improved salaries or student loan repayment programs, and improved job descriptions and recruitment marketing tools and trainings for health departments, as well as training programs for job seekers seeking governmental public health jobs, could help to bridge the gap between job seekers and the public health workforce.

In recent years we see clear impact of law on the public’s health and public health systems. We have experienced unprecedented public health emergencies including a pandemic and loss of the federally protected right to reproductive autonomy, each of which disproportionately burden already-vulnerable communities.

Now more than ever, public health leaders need to be able to engage law and civic engagement to meet challenges new and old.  Leveraging the multi-disciplinary faculty within the Department and the school, students are equipped to design nonpartisan, research-backed legislation and regulation focused on today’s most critical public health issues.

Professor Schaler-Haynes leads the Center’s work on public health law and civic engagement.  Her career spans two decades in multiple public service roles. She offers a unique breadth of expertise in governmental public health as well as legislative, regulatory, and litigation-based health care coverage, access, and delivery initiatives. In the fall of 2022, after adjunct teaching courses in public health law and abortion law for 15 years while working as a practitioner, Professor Schaler-Haynes transitioned from public service to full-time academia. In joining public health academia, she works to deepen public health’s understanding of the rule of law and to build capacity to “think and do” through civic engagement and design of impactful, evidence-based policy initiatives using tools of law.  

In Fall of 2024, Professor Schaler-Haynes and Dr. Heather Krasna were awarded CDC funding to increase implementation of public health law curricula in accredited schools and programs of public health. This Cooperative Agreement funding is part of the CDC initiative “Strengthening Public Health Systems and Services through National Partnerships to Improve and Protect the Nation’s Health.”  Today, the accredited MPH programs are not required to teach law or to meet any competencies in law. The project is an effort to make law more accessible to the public health field using established curricular resources, to support the work of local health departments and to incentivize MPH programs to offer basic courses and training in public health law. 

The COVID-19 pandemic exposed the shortcomings of the UnitedStates public health system. High on the list is a public health workforce thatis understaffed, underpaid, and undervalued. To rebuild that workforce, theAmerican Rescue Plan (ARP) appropriated $7.66 billion to help create 100,000new public health jobs. As part of this initiative, the Centers for Disease Controland Prevention (CDC) distributed roughly $2 billion to state, local, tribal, andterritorial health agencies for use between July 1, 2021, and June 30, 2023. At the same time, several states have enacted (or are considering enacting) initia-tives to increase state funding for their local health departments with the goal ofensuring that these departments can deliver a core set of services to all residents.The differences in approach between this first round of ARP funding and theseparate state initiatives offer an opportunity to compare, contrast, and suggestlessons learned.

After interviewing leaders at the CDC and other experts on thenation’s public health workforce, we visited five states (Kentucky, Indiana,Mississippi, New York, and Washington) to examine, by means of interviewsand documents, the implementation and impact of both the ARP workforcefunds as well as the state-based initiatives.

Three themes emerged. First, states are not spending the CDC work-force funding in a timely fashion; although the specifics vary, there are severalorganizational, political, and bureaucratic obstacles. Second, the state-based ini-tiatives follow different political paths but rely on the same overarching strat-egy: gain the support of local elected officials by providing funding directly tolocal health departments, albeit with performance strings attached. These stateinitiatives offer their federal counterparts a political roadmap toward a morerobust model of public health funding. Third, even with increased funding, wewill not meet the nation’s public health workforce challenges until we makepublic health a more attractive career path (with higher pay, improved workingconditions, and more training and promotion opportunities) with fewer bureau-cratic barriers to entry (most importantly, with less reliance on outdated civilservice rules).

The politics of public health requires a closer look at the roleplayed by county commissioners, mayors, and other local elected officials. Weneed a political strategy to persuade these officials that their constituents willbenefit from a better public health system.

View the full article published in The Milbank Quarterly.

Building off her career in public service, Professor Schaler-Haynes’ research explores public health and health equity in the context of healthcare professional licensure. To the extent the healthcare workforce functions as a public good, policy can be designed to support or constrain its development, quality, retention, modernization, and ability to efficiently respond to surges in demand. State laws regulating the health professions are essential to secure public safety and increase provider supply. Workforce shortages and public health emergencies such as COVID-19-era suggest the need for optimization and coordination across agencies to efficiently plan for the next public health crisis. Evaluation and refinement of COVID-19-era policies offer a basis to improve public health law and policy by addressing workforce capacity, scopes of practice and interstate licensing compacts.

As a member of New Jersey’s COVID-19 response team, Professor Schaler-Haynes established a foundation-funded state agency–university partnership to evaluate utilization of New Jersey’s temporary out-of-state health care provider licensure program which issued >30,000 temporary licenses. This evaluation, published in Health Affairs, informs innovative planning strategies to encourage mobility of healthcare workforces for future public health emergencies.  A second evaluation of the program focuses on mental health providers who comprised over 25% of temporary licensees. Published in the Journal of Medical Regulation, this work examines the extent to which temporary licensure programs increased access to a diverse mental health workforce. Findings suggest that temporary licensure programs allowing out-of-state-providers to offer care in person and via telehealth can be valuable short-term strategies to mitigate workforce shortages during emergencies.

Professor Schaler-Haynes’s recent work focuses on evidence-based modernization of state laws regulating the practice of midwifery as a strategy to improve maternal health outcomes. Access to midwifery care is part of a comprehensive solution to the ongoing maternal health crisis.  Increased access to midwifery care is associated with improved maternal outcomes such as decreased rates of surgical birth, increased patient satisfaction and cost containment. Schaler-Haynes recently published a policy brief identifying how to leverage state midwifery laws to improve equity, access, and outcomes. Optimizing laws relating to the regulation of midwifery practice includes, for example, consideration of autonomous practice, credentialing and privileging, malpractice insurance, prescriptive authority and scopes of practice.