Strengthening Public Health Systems Across State Lines

Hanover Street in Fall by David Bagley

Reflections from PHC’s 2025 Legislative Breakfast

On October 31, the Public Health Council of the Upper Valley (PHC) convened legislators, public health leaders, healthcare providers, and community partners for our fifth Upper Valley Bi-State Legislative Breakfast. Held in Lebanon, NH, the 2025 event focused on how public health systems are structured, funded, and coordinated across New Hampshire and Vermont, and what those systems mean for the health of Upper Valley residents.

PHC’s legislative events are designed to support informed, nonpartisan policymaking by bringing together the people who experience policy impacts daily with the lawmakers who shape them. This year’s conversation underscored a simple truth: in a rural, bi-state region like the Upper Valley, public health challenges do not stop at the border, and neither can solutions.

Public Health Systems: Capacity, Coordination, and Core Functions

The morning began with a discussion of core public health functions and the ways legislatures influence public health capacity through governance, statutory authority, and funding. Speakers highlighted that public health operates across multiple levels (federal, state, regional, and municipal) and depends on coordination among these systems to function effectively.

Participants reflected on how public health is often forced into a reactive posture, responding to emergencies rather than investing in prevention and long-term planning. While a fully resourced public health system may not be immediately attainable, speakers emphasized the importance of using core public health functions as a guiding framework for policy decisions and incremental improvement. 

Differences between Vermont’s and New Hampshire’s public health structures were also explored. Vermont’s Public Health Caucus was discussed as a model for legislative education and engagement, helping integrate public health considerations across policy areas. In contrast, New Hampshire’s regional public health networks were described as operating with limited and unstable funding, constraining their ability to plan, retain staff, and meet growing community needs. 

Local Public Health and the Role of Town Health Officers

A significant portion of the discussion focused on the role of Town Health Officers (THOs) and local public health capacity. Speakers noted that while THOs are statutorily required in every New Hampshire municipality, many serve part-time or in volunteer roles, often balancing multiple municipal responsibilities.

This structure can limit the ability of local public health officials to focus on prevention, education, and community engagement. Participants discussed alternative models, such as shared or regional health officers and mutual-aid style agreements, that could strengthen local public health capacity while remaining responsive to political and legislative realities.

Housing as a Public Health Issue

Housing emerged as a central theme throughout the breakfast. Presenters emphasized that homelessness is fundamentally a housing problem, driven by affordability constraints and limited supply rather than individual behavior. 

Speakers shared data and lived experience illustrating how evidence-based Housing First approaches improve housing stability, reduce emergency department use, and lower overall public costs compared to crisis-driven systems. The conversation also highlighted the growing need for accessible and universally designed housing in a region with an aging population and high rates of disability.

Participants discussed policy strategies that can expand access to safe, stable housing while supporting independence, dignity, and long-term health outcomes for Upper Valley residents.

Medicaid Policy and Rural Healthcare Impacts

The final major topic of the morning addressed potential changes to Medicaid and healthcare financing and how these changes may ripple through Upper Valley communities. Speakers outlined how increased eligibility reviews, work requirements, and funding constraints could lead to coverage losses, delayed care, and increased reliance on emergency services.

Rural healthcare providers, including hospitals, long-term care facilities, and community mental health organizations, were identified as particularly vulnerable to funding disruptions. Participants emphasized that cuts to Medicaid do not occur in isolation but instead create cascading effects across healthcare and social service systems.

Building Understanding Through Ongoing Dialogue

During closing reflections, legislators emphasized the value of hearing directly from public health practitioners and community partners. Several noted that repeated exposure to local data, lived experience, and system-level analysis builds understanding over time and supports more informed policymaking on complex issues.

PHC has shared a full report [2025 UV Legislative Event Report] from the event with policymakers serving the Upper Valley and will continue to serve as a resource for legislators seeking local context, data, and connections to community experts.

As PHC looks ahead to future legislative events, we remain committed to fostering dialogue that reflects the realities of living and working in a rural, bi-state region, and to supporting policies that strengthen the systems Upper Valley residents rely on every day.

— Written by Vismaya Gopalan, ’82 UVCI Fellow to the PHC, Dartmouth College

— Published by the Valley News on February 12, 2026, as “What public health in the Upper Valley has taught me.”