Making the Case for Foundational Public Health Services Barry Kling, Administrator Chelan-Douglas Health District www.nwcphp.org/hot-topics
Public Health Funding System is Broken We consider it success when we don t get cut much Inflation and population growth have undermined our budgets Not just the Great Recession, it s a long term structural defect The most basic public health services are threatened
What We Need Stable support Funding that tracks with population & inflation Ensure that every community has what we need everywhere for the system to work anywhere. Recognizing the basics aren t all we should do. This is Foundational Public Health.
The Question Decision makers will want to know what they get for the money If you say trust us, the conversation soon ends For sustainable funding, assemble an honest list of public health basics
Why Foundational Public Health? To secure sustainable funding for basic public health services statewide
The Institute of Medicine Agrees Basic public health funding is a national problem Need to define the basics in order to fund them Washington s Foundational list being used as a starting point by CDC/Robert Wood Johnson Foundation workgroup in first round
What We Need To Do Define Foundational Public Health Services Cost them out statewide Develop practical policy options for sustainable Foundational funding Develop a broad based coalition of supporters Advocate for the necessary legislation Don t quit
Foundational Public Health Foundational instead of minimum, basic, or core Not the whole house, but house doesn t work unless the foundation is solid Public Health Improvement Partnership (state/local) workgroup began in 2011 Proposed Foundational Services list was widely shared, discussed, and modified in 2012
Issues in Defining Foundational Services What we need to do everywhere for the system to work anywhere, but not everything we need to do Capabilities and services have to be specific enough to cost them out Must take into account a responsibility for population-based issues and services
Foundational Public Health Services Foundational Public Health Services Examples of Additional Important Services Foundational Program Foundational Capabilities Communicable Disease Control Chronic Disease & Injury Prevention Environmental Public Health Maternal/Child/Family Health Access/Linkage with Clinical Health Care Across all programs Assessment (surveillance and epidemiology) Emergency preparedness and response (all hazards) Communications Policy development and support Community partnerships development Business competencies Vital Records Washington State Public Health Improvement Partnership Agenda for Change, January 10, 2013
The Process Individual services were evaluated on a spectrum (more on next slide) using both empirical evidence and subject matter experts List vetted widely in government public health community summer 2012 Key point: list had to be specific enough to be costed out
Foundational Public Health Decision Matrix Population-based To what extent are beneficiaries individuals or populations? Mainly provides individual benefits Partially population based, absence would pose a significant community health threat Population-based preventive health service addressing an important health problem Governmental public health To what extent is governmental public health the only or primary provider of this service? Never many other entities provide this service Sometimes Often must be addressed by governmental public health to be effectively addressed Mandatory Is it mandated by law or a legal power granted only to the local authority? Not mandated Partially or sometimes Definitely mandated
How Definitions Were Developed: The Workgroup Whatcom Northeast Tri County Snohomish King Chelan-Douglas Lincoln Spokane Pierce Grant Walla Walla Clark Klickitat
Example: Environmental Health The foundational definition for Environmental Public Health includes: 1. Provide timely, statewide, and locally relevant and accurate information to the state and community on environmental public health issues and health impacts from common environmental or toxic exposures. 2. Identify statewide and local community environmental public health assets and partners, and develop and implement a prioritized prevention plan to protect the public s health by preventing and reducing exposures to health hazards in the environment. 3. Conduct mandated environmental public health laboratory testing, inspections, and oversight to protect food, water recreation, drinking water, and liquid and solid waste streams in accordance with federal, state, and local laws and regulations.
Environmental Health, Cont. 4. Identify and address priority notifiable zoonotic (e.g., birds, insects, rodents) conditions, air-borne, and other public health threats related to environmental hazards. 5. Protect workers and the public from unnecessary radiation exposure in accordance with federal, state, and local laws and regulations. 6. Participate in broad land use planning and sustainable development to encourage decisions that promote positive public health outcomes (e.g. consideration of housing, urban development, recreational facilities, and transport). 7. Coordinate and integrate other categorically-funded environmental public health programs and services.
Example: Communicable Disease The foundational definition for Communicable Disease Control includes: 1. Provide timely, statewide, and locally relevant and accurate information to the state and community on communicable diseases and their control, including strategies to increase local immunization rates. 2. Identify statewide and local communicable disease control community assets, develop and implement a prioritized communicable disease control plan, and advocate and seek funding for high priority policy initiatives. 3. Ability to receive laboratory reports and other identifiable data, conduct disease investigations, including contact notification, and recognize, identify, and respond to communicable disease outbreaks for notifiable conditions in accordance with national and state mandates and guidelines.
Communicable Disease, Cont., 4. Assure the availability of partner notification services for newly diagnosed cases of syphilis, gonorrhea, and HIV according to Centers for Disease Control and Prevention (CDC) guidelines. 5. Assure the appropriate treatment of individuals who have active tuberculosis, including the provision of directlyobserved therapy according to CDC guidelines. 6. Assure availability of public health laboratory services for disease investigations and response, and reference and confirmatory testing related to communicable diseases. 7. Coordinate and integrate other categorically-funded communicable disease programs and services.
Example: Chronic Disease/Injury Prevention 1. Provide timely, statewide, and locally relevant and accurate information to the state and community on chronic disease prevention and injury control. 2. Identify statewide and local chronic disease and injury prevention community assets, develop and implement a prioritized prevention plan, and advocate and seek funding for high priority policy initiatives. 3. Reduce statewide and community rates of tobacco use through a program that conform to standards set by Washington laws and CDC s Office on Smoking and Health, including activities to reduce youth initiation, increase cessation, and reduce secondhand smoke exposure. 4. Work actively with statewide and community partners to increase statewide and community rates of healthy eating and active living through a prioritized program of best and emerging practices aligned with national and state guidelines for health eating and active living. 5. Coordinate and integrate other categorically-funded chronic disease and injury prevention programs and services.
The Cost-Out Process Consultants helped develop a cost model for Foundational Public Health Developed detailed cost model with nine jurisdictions Each jurisdiction completed questionnaire and in-depth interviews Cost data were extrapolated
The Nine Local Health Jurisdictions Whatcom 203,500 Northeast Tri-County 7,650 43,600 13,100 Seattle-King County 1.9 million Chelan-Douglas 73,200 38,900 Grant 90,100 Lincoln 10,375 Spokane 475,600 Walla Walla 59,100 Clark 431,250 Total population Washington: 6,817,770
Public Health Spending Estimate Estimate of Current Spending on Foundational Services Public Health Current Spending (2013 $) Department of Health (DOH) Amount % of DOH Local Health Jurisdictions (LHJ) Amount % of LHJs System Total Amount % of Total 157.6 M 31% 141.0 M 40% 298.5 M 35% Foundational Capabilities 26.2 M 36.3 M 62.5 M Foundational Programs 131.4 M 104.7 M 236.1 M Estimate of Current Spending on Additional Important Services* 347.0 M 69% 215.0 M 60% 562.0 M 65% Total Public Health Spending 504.5 M 356.0 M 860.5 M * Excluding LHJ Pass-through dollars Source: Department of Health 2013, BARS, 2013; nine sample LHJs, 2013 and BERK 2014
The Costs Preliminary Foundational Public Health Services Numbers
The Costs Preliminary Numbers in Detail
The Gap: Preliminary Per Capita Estimate Clallam 71,600 $11 Jefferson 30,050 $13 Grays Harbor 30,050 $18 Pacific 20,900 $40 San Juan 15,900 $18 Mason 61,100 $15 Wahkiakum 4,000 $117 Island 78,800 $18 Kitsap 253,900 $17 Thurston 254,100 $18 Cowlitz 102,700 $21 Clark 428,000 $10 Whatcom 202,100 $13 Skagit 117,400 $10 Snohomish 717,000 $14 Seattle-King County 1.9 million $6 Tacoma-Pierce 802,150 $5 Lewis 76,000 $17 Okanogan 41,200 $18 Chelan-Douglas 111,350 $10 Kittitas 41,300 $19 Yakima 244,700 $17 Skamania 11,150 $36 Klickitat 20,500 $38 Grant 90,100 $18 Benton-Franklin 258,400 $26 Northeast Tri-County 64,200 $15 Lincoln 10,600 $48 Adams 18,950 $38 Walla Walla 58,800 $27 Spokane 472,650 $5 Whitman 44,800 $36 Garfield 2,250 Columbia $221 4,100 $140 Asotin 21,650 $26
Funding Issues Under Discussion Local per-capita costs and contributions State contributions to local jurisdictions State vs. local responsibilities for foundational public health? Can costs be managed through structural changes like consolidation or service sharing? New funding sources?
Local Health Jurisdiction Funding By Source Overall 2011 State Funds As % of Total Revenue 17% Federal Funds As % of Total Revenue 39% Local Funds As % of Total Revenue 44%
Local Health Jurisdiction Funding By Source Details
Percap Local Health Jurisdiction Funding By Source
Percap Local Health Jurisdiction Funding & Wealth
Next Steps: Policy Options Secretary of Health convening stakeholders (e.g., elected officials local Board of Health members) to explore policy issues from April December 2014 Developing specific policy options and proposals for sustainable funding Develop preliminary proposals for 2015 legislative session
Next Steps: Advocacy Develop broad support for sustainable funding proposals Work with doctors, nurses, hospitals, clinics, major employers, and unions Substantial headwinds in the legislature, but will be opportunities in future Seize that opportunity
Next Steps: Don t Quit Probably won t pass the first time or maybe the 2 nd and 3rd. Must have the staying power to see it through.
Questions and Discussion
Contact Information: Barry Kling, Administrator Chelan-Douglas Health District 200 Valley Mall Parkway East Wenatchee, WA 98802 Office 509-886-6480, cell 509-264-7045 Barry.kling@cdhd.wa.gov