The COVID-19 pandemic has laid bare the limits of New Mexico’s understaffed and highly centralized public health system.
Unlike most other states, New Mexico does not have county-based health boards. Instead, public health services like vaccination have traditionally fallen to the chronically understaffed state health department, which has struggled to contain the pandemic’s spread.
“The big lesson is that we’ve underfunded public health,” said Sen. Jerry Ortiz y Pino, D-Albuquerque. “Our infrastructure was woefully inadequate and now we’re paying the price.”
That includes funding for the state’s 42 county and tribal comprehensive community health planning councils that, in the absence of local health boards, fill an important role identifying local public health gaps and needs. Many of the health councils have gone beyond their statutory mandates, in recent months, to pitch in with local COVID response efforts – helping to coordinate local testing and vaccination efforts, get word out to local residents about where they can get booster shots, and at times serving as an important channel of communication between state health officials and local governments.
But the health councils are woefully underfunded, despite legislation passed in 2019 that expanded their mandates and directed the health department to provide them more funding. In 2022, with the state’s coffers busting at the seams, advocates and their allies in the Legislature want to see the state ensure councils’ long-term sustainability.
Boots on the ground
Health councils have been epicenters of local public health planning for more than 20 years, conducting local health needs assessments and advising local governments on solutions. (Health councils assess local health issues and help plan health care responses, but until recently, they did not deliver health care services.)
They are invaluable sources of insight about local issues in the state’s often-neglected rural areas, said Rep. Gail Armstrong, R-Magdalena.
“They are the boots on the ground in our communities,” Armstrong said. “They know what the needs are. But a lot of people don’t even know they exist or what they’re for.”
Lawmakers depend on health councils as a reliable and objective source of information about local public health challenges, Ortiz y Pino agreed.
The Rio Arriba County Health Council, for instance, was spotlighted last year by reporter Ted Alcorn in the Washington Post for its work with the Española Police Department to train officers in naloxone administration to reverse opioid overdoses. Rio Arriba County has long been an epicenter of opioid overdose deaths.
“Rio Arriba was able to quickly refocus the infrastructure we’d created for addressing one epidemic, Substance Use Disorder, to combat the new pandemic, COVID-19,” Lauren Reichelt, of the Rio Arriba County Health Council, said in an interview. “We organized volunteers to make and distribute 10,000 masks, 800 gowns and hundreds of face shields throughout northern New Mexico early in the pandemic.”
The health council also created new COVID testing sites, coordinated testing clinics, and are coordinating school-based vaccine clinics throughout the county, Reichelt told New Mexico In Depth.
“As a result, we are among the most vaccinated counties in the U.S.,” she said.
The health councils were not originally created to help respond to fast-moving emergencies like infectious disease pandemics. They evolved from local maternal and child health councils in the 1990s into comprehensive health planning groups tasked with identifying and informing policymakers about local chronic health problems and needs. “We know that only 20% of health outcomes are the result of health care,” Sharon Finarelli, executive director of the New Mexico Alliance of Health Councils, said. “Consequently, health councils’ focus on the social determinants of health, to work on the 80% that is responsible for community health outcomes in our COVID vaccine equity work.”
Many experts point to poverty and one’s race and ethnicity as key factors in a community’s struggles with poor health outcomes.
For most health councils, tackling an immediate crisis like the pandemic is new, Finarelli acknowledged.
“We’re moving so fast it’s like we’re putting down the railroad ties as the engine’s coming over them,” said Anne Hays Egan, a public health consultant, about some health councils’ new, direct participation in local pandemic responses.
That work has been challenging at times. The state was slow to share detailed COVID infection and vaccination rate data with local governments and health councils for targeted community-based interventions. Originally, in 2020, the state health department disclosed only county-level data. In early December 2021, they agreed to provide Zip-code level data to the N.M. Community Data Collaborative (NMCDC) and health department analyses of that data (but not the data itself) to health councils. But it was not clear how Zip code-level data could be used to identify individual neighborhoods or census tracts that might be falling between the cracks.
The NMCDC is using the health department data to create data dashboards for county and tribal health councils.
But even as health councils’ responsibilities grow, sustainable funding remains in doubt. Since the Great Recession, they have struggled.
Underfunded
In 1991, the New Mexico Legislature mandated the creation of county maternal and child health planning councils, funded through the state health department. In 2007, lawmakers amended the Maternal and Child Health Plan Act to include tribal health councils.
“By 2010, the health council system as a whole was receiving $2.8 million annually in state funding,” said Ron Hale of the New Mexico Alliance of Health Councils, which was created that year.
But then came the Great Recession. The state suspended funding for the councils between 2010 and 2014, forcing some to curtail or cease their work. Rural health councils were hardest hit.
“They just got wiped out,” Ortiz y Pino said.
Health council funding hasn’t neared 2010 levels since.
“Amounts of annual appropriations have varied widely, up to a maximum of $395,000” for all councils combined, Hale said.
In 2019, the Legislature passed the County and Tribal Health Care Act (HB 137), tasking health councils with identifying local health needs, resources, and priorities. The law directed the state health department to administer funding for health council staff and training, and to develop guidance and benchmarks for measuring health councils’ success and “mechanisms to ensure the long-term viability of health councils.”
Nearly three years later, however, the state has yet to make good on those mandates. Finarelli and health department officials are still in talks to create a committee to develop the HB 137-mandated benchmarks and guidance.
And even when combined with temporary pandemic-related nonprofit grants, the current state funding is enough for no more than one full-time staff member at each council, Finarelli noted. (State general fund support comes to just under $9,500 for each health council. That plus funding from the W. K. Kellogg Foundation and U.S. Centers for Disease Control and Prevention means funding for each health council is “just shy of $60,000,” she explained.)
That funding supports staffing but not support for equipment, supplies, rental fees, and other expenses, Finarelli noted. “We estimate that it would take about $100,000 per county or tribe to fully fund a health council.”
Fully funding all health councils statewide and the Alliance would come to $5 million a year, she said.
As of December, 37 health councils were receiving health department-administered Kellogg and CDC vaccine equity and community health rebuilding grants. (Two additional tribal health clinics might join them this month.) Those grants are worth $50,000 each year but will run out in June 2023. The Robert Wood Johnson Foundation, Presbyterian Healthcare Services, and Con Alma also awarded modest grants to health councils and the Alliance.
That grant money is crucial for rebuilding health council capacity, noted Susan Wilger, of the Center for Health Innovation. But it is not enough to make health councils sustainable over the long haul, she, lawmakers, and health council officials agreed.
“A grant is a grant: after two years, it goes away,” Armstrong said. “That’s the problem. They’re on a rollercoaster.”
As of early December, the state health department had not drafted any legislative requests for health council funding for this session but a spokesperson said in an email that “it is possible there may be one coming, as the department works through the implementation of HB 137.”
Armstrong, who serves on the House appropriations and legislative finance committees, has requested appropriation this legislative session of an additional $75,000 in health council funding through the health department. But that money would have to be split among all health councils, statewide, she acknowledged.
“I think there will be an effort made to expand the funding available for all of them through the DOH budget,” said Ortiz y Pino. The only other realistic mechanism for health council funding this session will be lawmakers’ individually assigning funds under their control, called “junior money” appropriations, Ortiz y Pino said.
“They could try to introduce a separate bill, but if it’s not in House Bill 2 [the general appropriations bill], the odds of it getting approved go down to practically zero,” he said.
Tribal Health Councils
Tribal health councils – and coordination between county and tribal health councils – will be key to building a stronger public health system in New Mexico, proponents believe. The Navajo Nation and several Indian Pueblo communities were among those hardest hit by the COVID pandemic.
Nine tribes currently have active health councils: the Cañoncito Navajo Band in To’hajiilee and eight Indian Pueblo tribes: Acoma, Cochiti, Nambe, San Ildefonso, Santa Clara, Santo Domingo, Picuris, and Tesuque. The pueblos of Nambe, Picuris, and Santo Domingo established health councils in 2021 and the Santa Clara Indian Pueblo is in the early stages of rebuilding its health council, said Tribal Liaison Gerilyn Antonio, who is Diné. She joined the New Mexico Alliance of Health Councils in June.
The Alliance hopes to help establish two new tribal health councils each year, Finarelli said. But that will depend on state funding, she cautioned. Many tribal communities have chosen not to participate yet in establishing or reestablishing health councils because of uncertain funding.
Public health in Native communities is even more complex than elsewhere, with important roles for information sharing between the tribes, counties, state agencies and federal Indian Health Service.
Trust is another factor.
“I do see some tribal communities maybe who do not want to accept state funding,” Antonio said. “I think that is part of navigating historical trauma that’s happened and working with outsiders. We need to try to build better relationships.”
The tribes are also anxious to protect their health data sovereignty, Antonio noted. The New Mexico Community Data Collaborative is in discussions with tribal health clinics to determine exactly who will have access to their individual data dashboards.
Several tribes and tribal health councils are currently focused on delivering pediatric COVID immunizations and ensuring access to booster doses for adult tribal members, Antonio said. “We see a lot of high vaccination rates in some of the pueblos I work with,” she said. “Some ranging over 85%, which is really great. With so many tribal community members vaccinated, their focus has shifted to pediatrics and boosters.”
‘All Public Health is Local’
Health councils’ emerging role in helping develop locally tailored pandemic responses is a welcome move away from the state’s highly centralized system of public health, according to several local experts who spoke with New Mexico In Depth.
“New Mexico is a large state with a small and dispersed population,” said Richard Skolnik, a member of Los Alamos County’s recently reconstituted health council. “I understand why there is a unified state health system. Figuring out how best to handle public health, structurally, in New Mexico is a real challenge.”
But the pandemic has exposed “structural flaws that need to be overcome quickly,” Skolnik said. He noted as one example “gaps in communication” between state and local public health officials during a recent cluster of COVID cases in Los Alamos.
“There was no analysis of epidemiologic data” for the outbreak, Skolnik said. “There was no communication with the public about the sources of spread or how our personal and community response to the outbreak should be adjusted.”
Health councils can play a role in bridging gaps in pandemic responses, but that will require political will and sustainable funding mechanisms, said Skolnik, a former global health lecturer at Yale University, director of George Washington University’s Center for Global Health, and a retired World Bank director for health and education in South Asia.
Health councils “need resources to fulfill their mission,” he said. Skolnik spoke to New Mexico In Depth in his personal capacity, not as a representative of the county health council.
“All public health is local and, therefore, data and communication must be localized,” Skolnik said.
Editor’s notes: Correction: New Mexico In Depth received and added new information that Presbyterian Healthcare Services has supported the health councils over the years. Disclosure: The W.K. Kellogg Foundation and Con Alma fund New Mexico In Depth.