Keeping Texas Healthy Is Costly
Public Health Feature – February 2012
Tex Med. 2012;108(2):41-48.
By Crystal Conde
Maintaining an adequate local public health infrastructure is increasingly difficult in the wake of budget cuts. Last summer, the Lubbock City Council proposed outsourcing surveillance, sexually transmitted disease (STD), and immunization services to trim about $1.2 million from the city's budget for 2012-13. In response to the plan, many Lubbock physicians, health professionals, medical students, residents, and Lubbock-Crosby-Garza County Medical Society Alliance members rallied to advocate for public health services to remain under one roof within the City of Lubbock Health Department. (See "Keeping Lubbock Healthy," January 2012 Texas Medicine, pages 39-43.)
Attempts by Lubbock city officials to outsource clinical health services for efficiency could signal a statewide trend, according to W.S. "Chip" Riggins Jr., MD, MPH, executive director and local health authority of Williamson County and Cities Health District (WCCHD).
"I think it's clear that regardless of what happens with health care reform, funding the medical model alone can't create healthy communities or ensure that we reach our community goals for health and reduction of health disparities. Our local public health agencies need to be made secure enough in their role and funding to serve as facilitators of a collaborative and proactive process to continuously improve the health of their communities," said Dr. Riggins, a member of TMA's Council on Science and Public Health.
James Morgan, MD, assistant commissioner of the Texas Department of State Health Services (DSHS) Regional and Local Health Services Division, says state appropriations to local health departments for services such as immunizations, tuberculosis (TB), and STD prevention haven't changed much for fiscal year (FY) 2012, which runs from September 2011 to August 2012.
A broad look at the budget shows immunization funding remained the same from FY 2010-11 to FY 2012-13 at $169.7 million. HIV/STD prevention funds dropped $28.5 million from FY 2010-11 ($362.6 million) to FY 2012-13 ($334 million). Funding for TB falls under the infectious disease program, which went from $84 million in FY 2010-11 to $81.6 million in FY 2012-13.
Dr. Morgan notes that "any reductions in funding at the program level – infectious disease, for instance – don't necessarily translate to reductions in local health department contracts."
"While DSHS has seen a reduction in the amount appropriated under the HIV/STD prevention strategy, for example, there won't be a major change in the amounts contracted with local health departments for STD services, or immunizations or TB for that matter," he said.
State and federal funding for family planning, which some health departments provide, as well as federal funding for emergency preparedness and preventive health, is another story.
The state budget for family planning services went from $111.5 million for FY 2010-11 to $37.9 million for FY 2012-13, including federal funds. DSHS isn't aware of any additional reductions in federal funding for family planning. Dr. Morgan says public health agencies that provide clinical family planning services likely will feel the impact of the two-thirds drop in available state funding.
On top of that, local health departments in Texas experienced a 16-percent reduction in federal Public Health Emergency Preparedness (PHEP) base funds for FY 2012. Eight health service regions that carry out local public health functions for areas not served by a local health department or district took an 18-percent reduction, and the DSHS central office preparedness program dropped 22 percent. Dr. Morgan says the reductions were necessary to limit local health department and district reductions to only 16 percent. As a whole in FY 2012, reductions to the PHEP base grant for Texas total $6 million, leaving the state with about $31 million.
The Cameron County Health Department uses PHEP funds for a dengue fever project focused on educating health care professionals about reporting diseases to the local or state health department. Other departments use the funds in a variety of ways, from outreach to Medical Reserve Corps projects.
The federal preventive health services block grant funded approximately 19 percent – about $1.4 million – of the local public health services grants to local health departments and districts. Dr. Morgan says these funds are absent from President Obama's budget and the Senate budget and likely "won't be continued." State funding for preventive health services for FY 2012 is about $6 million.
Dr. Morgan says the preventive health services block grant provides flexible funding that local health departments can use for any public health function, such as maintaining an STD clinic or hiring an epidemiologist.
Funding reductions should never threaten a local health department's ability to provide essential services, Dr. Riggins says.
"I believe that if public health agencies continue to be funded to be the safety net for clinical, communicable, indigent health care rather than to be the complementary system that proactively synergizes the health care system toward healthier populations, we will see communities struggle," Dr. Riggins said.
"Public health funding is and will continue to be a complex issue," said DSHS Commissioner David Lakey, MD. "With the geographic and population diversity of Texas, there likely is no clear funding model to fully address every need. We will continue working collaboratively with our health department partners to develop a sustainable approach to funding core public health services."
Committee to Examine Funding
In the wake of a grim economy and dwindling public health funding, local and state health officials hope a new committee established this past legislative session under Senate Bill 969 by Sen. Jane Nelson (R-Flower Mound) will help local health departments and DSHS develop new policies and funding mechanisms to improve support for the public health system.
SB 969 amends the Health and Safety Code to establish the Public Health Funding and Policy Committee within DSHS. The committee's first charge is to define the core public health services a local entity should provide to establish a common definition for what should be funded.
In 1999, Texas became the first state to codify into law 10 essential public health services to provide a working definition for local public health systems. (See "10 Essential Public Health Services.") Dr. Riggins says despite Texas' early adoption of the essential services, many disparate definitions of public health exist.
"Recent events suggest that our public health policy, especially as it pertains to services at the local level, has not kept pace in this rapidly changing health care environment," he said.
Next, the committee will evaluate the state's public health system in relation to those services and identify areas for improvement. The committee also will identify all funding sources available for use by local health entities to perform the core public health services. Finally, committee members must establish public health policy priorities.
Each year, the committee will present a report on its activities to the legislature that includes recommendations on the use and allocation of funds, ways to improve the overall health of Texans, and the contracting process for local public health services while sustaining a collaborative relationship between DSHS and local public health departments.
"When funding comes to DSHS, we have to take into consideration a lot of competing interests. For instance, the committee will help us determine how to allocate funding in rural and urban areas. In the past, we haven't had any uniform way of looking at allocating funding across the state," Dr. Morgan said.
He adds that committee members represent communities of varying sizes throughout Texas. (See "DSHS Public Health Funding and Policy Committee Members.")
Stakeholders and the public will have semiannual opportunities to provide input to the committee. For updates on committee meetings open to the public, visit www.dshs.state.tx.us.
Mark Guidry, MD, MPH, health authority for Galveston County & Cities and chief executive officer of Galveston County Health District (GCHD), is a member of the committee. He describes Texas' public health infrastructure as "fragmented and diverse."
"In many ways, it's broken. Because there is no clear, current scope of services defining what a health department should do, public health infrastructure is vulnerable to any changes in policy and funding," he said.
Public Health on Alert
WCCHD receives about 25 percent of its total budget (excluding the Women, Infants and Children [WIC] program) from state and federal sources and about 75 percent from Williamson County and cities' general funds, as well as from fees. The district collects fees primarily for environmental health services, such as restaurant permits, septic system licensure, and copayments for services such as immunizations.
Dr. Riggins says WCCHD's state and federal contracts amount to about $1 million per fiscal year, representing reductions in the neighborhood of $150,000 for FY 2012.
"We also have seen the last of the Public Health Emergency Response funding that we've had for several years," Dr. Riggins said.
For fiscal years 2009, 2010, and 2011, WCCHD received federal Public Health Emergency Response (PHER) funds totaling $1.2 million. In response to the 2009 H1N1 influenza pandemic, CDC administered funding through the PHER grant to upgrade state and local preparedness and response capacity during the pandemic.
Dr. Riggins says the district used the funding to enhance hardware and software for disease surveillance, improve pandemic plans and training curricula, and hire temporary staff to support the Medical Reserve Corps volunteer program.
Despite funding constraints, Dr. Riggins says WCCHD is fortunate. Years ago, the district consolidated most of its clinical services with its community health center partner, Lone Star Circle of Care. While the health district does provide some immunizations, the community health center provides the bulk of clinical services, such as prenatal care and well child care.
"WCCHD was relatively spared from some of the larger reductions that affected health departments that provide more clinical safety net services," Dr. Riggins said.
Safety net services refer to clinical services public health agencies provide as part of the health care system. These could include preventive services such as prenatal care, well child exams, family planning, and immunizations. Consolidating clinical services allows WCCHD to focus on providing essential services while building and maintaining collaborations that allow a full-service health department to function effectively, Dr. Riggins says.
Dr. Guidry says his district has witnessed a reduction in funding. State and federal funds for FY 2010 totaled $3.9 million. The district received only $3.14 million for FY 2011 and about $2.8 million for FY 2012.
GCHD's public health improvement grant had a reduction of $60,000, while emergency preparedness funds dropped $25,800 and WIC funds went down $55,600 for FY 2012. GCHD's public health improvement grant focuses on wellness initiatives that promote healthy eating and exercise, and other activities.
The outlook for public health department funding – both federal and state – is fuzzy at this point, according to Dr. Guidry.
"In today's economy and with all the uncertainty about health system reform being implemented, tweaked, or repealed, it's hard to know what's going to happen. The general sense is that public health needs to be on alert," he said.
Dr. Guidry says virtually all public health funding is on the table, whether for disaster preparedness, infectious disease surveillance, or other key activities. And the future of health system reform will shape much of what happens.
"If health system reform is implemented the way it's currently written, most people will have health insurance. That could affect the services public health departments provide and associated funding levels. For example, immunizations provided by a local health department could disappear completely or significantly downsize because the need for health departments to provide them could decrease as more individuals have insurance to pay for them," he said.
In the face of uncertainty, Dr. Guidry says all public health departments "need to be vigilant about changes and plan ahead."
Decoding Public Health Funding
Trying to break down public health funding to local health departments in Texas is no easy task.
Dr. Morgan says the department funds local health departments in two ways: noncompetitive contracts renewed annually and competitive grants for which local health departments and other entities, such as community health centers, apply.
Adding to the complexity of how the state funds local health departments is the way money comes to DSHS, Dr. Morgan says.
"We have funding that comes from different federal sources, as well as state funding that goes to programs within DSHS. They all have different requirements for the use of funds," he said.
The legislature doesn't include a line item that spells out a specific appropriation for local health departments.
"We don't have a block grant of funding to local health departments that covers all necessary public health services and activities," Dr. Morgan said. "We have programs that contract with local health departments individually, such as money for STD and TB services and obesity prevention."
He says DSHS doles out funding to local health departments based on the need to conduct essential public health services, based on a formula, or based on sets of contracts awarded to entities.
Dr. Riggins says Williamson County and its cities have the distinction of being one of the healthiest Texas regions, which "probably works against us in terms of funding based on formulas. The better job we do in public health, the less disease happens and unfortunately, the less funding we may see until the next outbreak."
Dr. Guidry knows all too well the double-edged sword represented by funding formulas. He says his community must maintain a minimum of 15 TB cases to receive full funding for TB services. After Hurricane Ike, GCHD's level fell below the 15-case threshold, causing the district to lose its two TB contracts, which provided $126,000.
"After consulting with DSHS, we received general revenue funds of $100,000 for TB," Dr. Guidry said.
He says funding formulas for disease control in Texas should include two allocations – one that provides for disease prevention and surveillance and one that pays for treatment. The former amount would be fixed, and the latter amount would vary by community, depending on the number of disease cases. He says the DSHS Public Health Funding and Policy Committee may consider this method for funding formulas.
"The way the funding formula is set up now takes an all-or-nothing approach. If we don't have a certain number of cases of TB, for example, we lose all funding, including monies for prevention," he said.
Massive spreadsheets detail contracts DSHS has with local health departments. Making sense of the services each contract covers requires use of a decoding document that identifies each program and provides a description. For example, when sifting through DSHS funding spreadsheets, the abbreviation IMM/LOCALS is a common program identification that pops up. It stands for contracts covering immunization branch activities.
The decoding document elaborates to explain these contracts provide immunization branches with funding for essential public health services in collaboration with local health departments "to prevent and control the transmission of vaccine-preventable diseases in children, adolescents, and adults, with emphasis on accelerating strategic interventions."
Adding to the complexity, some contracts renew annually and cover ongoing public health programs, such as immunizations and STDs. Others are for short-term projects, such as CDC's pandemic flu planning or its PHER funds, which ran out in July. Additionally, funding spreadsheets provide a snapshot in time, as funds for the current year are always subject to change. Chris Van Deusen, DSHS assistant press officer, says it's possible some contracts haven't yet been executed, or health departments may opt out of some programs or add new programs.
"Bottom line, the raw numbers may not hold all the answers," he said.
Dr. Guidry says it's possible for a health department to have several contracts that fund specific program services that may or may not be relevant to a community. For instance, not all communities have a high incidence of HIV.
In addition, with every contract from DSHS, health departments must undergo an audit. Dr. Guidry says DSHS dispatches several employees who review one contract at a time for compliance, typically requiring several visits for each contract audit.
"Generally, not all of our contracts with the state renew automatically, so we have to write grants to renew them. Some grants are by calendar year, local fiscal year, or state fiscal year. The level of complexity is inefficient," Dr. Guidry said.
He says the DSHS Public Health Funding and Policy Committee will explore ways to fund local health department services. One option the committee may consider, he says, is providing one block grant to each local public health entity.
"This method would allow departments to provide relevant services at the community level in an efficient way by eliminating the need for multiple audits and grant applications," Dr. Guidry said.
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email.
Editor's Note: This is the second of Associate Editor Crystal Conde's two-part examination of public health in Texas. The first part in the January 2012 issue of Texas Medicine detailed the Lubbock medical community's efforts to preserve public health services within the Lubbock Health Department.
10 Essential Public Health Services
Texas state law establishes the essential public health services to be conducted by a local public health system. This system must:
- Monitor health status to identify and solve community health problems.
- Diagnose and investigate health problems and health hazards in the community.
- Inform, educate, and empower people about health issues.
- Mobilize community partnerships and action to identify and solve health problems.
- Develop policies and plans that support individual and community health efforts.
- Enforce laws and regulations that protect health and ensure safety.
- Link people to needed personal health services and assure the provision of health care when otherwise unavailable.
- Assure a competent public and personal health care workforce.
- Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
- Research new insights and innovative solutions to health problems.
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DSHS Public Health Funding and Policy Committee Members
Craig Blakely, PhD, MPH, College Station
Sandra Guerra, MD, MPH, San Antonio
Mark Guidry, MD, MPH, Galveston
Richard Kurz, PhD, Fort Worth
Deb McCullough, FNP, Andrews
Paul McGaha, DO, MP, Tyler
William S. "Chip" Riggins, MD, MPH, Georgetown
Stephen Williams, Houston
Victoria Yeatts, MSN, RN, Garland
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Preserving Public Health Services
By Donald R. May, MD
Efforts have been ongoing to preserve necessary public health care services in Lubbock by restructuring the Lubbock Health Department.
The City of Lubbock has made diligent efforts to best use existing funds to prepare for additional state and federal funding cuts. The intent has been to reduce the duplication of public health services in Lubbock, to move out of a deteriorating building and into newer and less costly facilities, and to ensure that the health department will continue to exist and provide the highest quality level of services.
The immense cost pressures of providing public health services, indigent health care, and other health services have impacted all communities and states. Most communities have severely decreased the size of their health departments over the past three years.
"Local health departments have been operating on leaner budgets and fewer staff since 2008," said NACCHO Executive Director Robert M. Pestronk. "Fewer staff means a loss of key protections for you and me. But with the loss also comes resourcefulness and innovating ways to make the most of the staff and funding that remain."
Federal Medicaid, Medicare, health insurance, and other health care mandates have greatly increased the cost of health care to states and communities. With the advent of Obamacare, massive additional amounts of federal health care dollars will go to pay the salaries of multiple layers of bureaucracies, leaving ever less money for health care services.
Federal and state grants for immunizations, sexually transmitted disease clinics, and other public health and indigent care services will quickly decrease, with much of the funding soon disappearing. The federal government intends to shift increasing amounts of the cost of Medicare, Medicaid, other indigent health care, and public health services to the states and communities.
State and local governments cannot afford to pick up the additional expenses. The only way city and county governments can support additional costs is to raise property tax rates, which has been a goal of the "politically correct."
The Lubbock Experience
Lubbock and other cities cut costs by consolidating duplicated services and contracting services to qualified health care providers. In Lubbock, we have the Lubbock Community Health Center, the Larry Combest Center, the Department of State Health Services (DSHS), and major hospitals and health care centers that provide immunizations and other clinical services.
The Lubbock Health Department resides in a remodeled 80-year-old building that needs about $1.5 million in renovations to keep it functional for the health department clinics, laboratories, and offices. The Lubbock City Council and city manager suggested relocating the health department offices, laboratories, and clinics to other facilities and closing the building now housing the health department.
Clinical services, including the immunization and sexually transmitted disease clinics, were to remain under the control of the Lubbock Health Department and were to be contracted to other health care providers in locations readily accessible to the public.
This announcement drew some confusion and public concern. Due to the concern, Steven Presley, PhD, chair of the Lubbock Board of Health, appointed me to chair a committee of board members and community professionals to evaluate these concerns and to bring recommendations to the board.
The situation was aggravated by false public claims that Lubbock would "become the largest city/county in the United States without public health services," which was stated on a public petition posted on a MoveOn.org website by members of a group called the Health Coalition of Lubbock. This misinformation excited a lot of people and escalated the matter to the point where our local county medical society, DSHS, and the Texas Medical Association became involved in this local partisan political matter.
It has been my impression that a primary intent of the Health Coalition of Lubbock has been to expand the size of the health department in a time when most cities are decreasing the size of their health departments. The health department was never in danger of closing. The "health conflict" that arose was political in nature and directed both at increasing the size of government in Lubbock and at attacking those who were seeking to reduce the duplication of services and consolidate essential services to reduce the size of Lubbock's government.
The committee I chaired believes the Lubbock Health Department continues to function very well. This was verified by the excellent handling of a recent hepatitis A incident in which one worker in a local restaurant was identified as infected with hepatitis A, with restaurant employees and several thousand patrons potentially exposed. Due to the rapid response of the health department and the City of Lubbock's Office of Emergency Management and Homeland Security to provide hepatitis A immunizations in a quickly organized clinic, no reported cases of hepatitis A resulted from this incident.
Our committee unanimously recommended that immunization and sexually transmitted disease services were essential public health services and that the City of Lubbock should continue to administer oversight. Our committee was politically bipartisan and included members of the Health Coalition of Lubbock.
A majority of Board of Health members thought it important to keep the immunization and sexually transmitted disease clinics in a single location. I disagreed with the board's decision and am of the opinion that immunization clinics, which are frequented by children as the patients, should be separate from sexually transmitted disease clinics. The Lubbock City Council will make further decisions.
Dr. May is a retina surgeon in Lubbock and a member of the Lubbock Board of Health.
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