Hearing Date: 1/21/21

Staff: Kim Weidenaar (786-7120).

Background:

Department of Health. 
The Department of Health (DOH) administers various programs and services that promote public health through disease and injury prevention, immunization, newborn screening, professional licensing, and public education.  Public health services are provided primarily by a decentralized system of 35 local health jurisdictions, the DOH, and the Washington State Board of Health (Board).

Local Health Department or District. 
Counties' legislative authorities are charged with establishing either a county health department or a health district to assure the public's health.  Local health departments and health districts can take various forms and include a single county health department or district, a combined city and county health department, or several counties can join a health district.  Each county department or health district has a local board of health, which is responsible for the supervision over all matters pertaining to the preservation of the life and health of the people within its jurisdiction.  Each local health jurisdiction must appoint a local health officer, who must be an experienced physician or osteopathic physician who has a Master of Public Health degree or equivalent.
 
Foundational Public Health Services. 
"Foundational public health services" is defined as a limited statewide set of defined public health services within the following areas:  control of communicable diseases and other notifiable conditions; chronic disease and injury prevention; environmental public health; maternal, child, and family health; access to and linkage with medical, oral, and behavioral health services; vital records; and cross-cutting capabilities including assessing the health of populations, public health emergency planning, communications, policy development and support, community partnership development, and business competencies.  "Governmental public health system" means the DOH, the Board, local health jurisdictions, sovereign tribal nations, and Indian health programs located in Washington.  "Service delivery models" means a systematic sharing of resources and function among state and local governmental public health entities, sovereign tribal nations, and Indian health programs to increase capacity and improve efficiency and effectiveness.
 
Foundational Public Health Services Funding.
Funding for foundational public health services must be appropriated to the Office of Financial Management (OFM).  The OFM may only allocate funding to the DOH if the DOH, after consultation with federally recognized Indian tribes pursuant to the statutory consultation process, jointly certifies, with a state association representing local health jurisdictions and the Board, to the OFM that there has been an agreement on the distribution and uses of state foundational public health services funding.  If joint certification is provided, the DOH must distribute the funding according to the agreed-upon distribution and uses.  If joint certification is not provided, the appropriation for foundational public health services lapses.

Summary of Bill:

Work Group.
A work group is established to develop and recommend to the Secretary of Health (Secretary) a public health system to provide foundational public health services through comprehensive public health districts and the Department of Health (DOH).  The work group consists of the following members appointed by the Governor to represent diverse geographic locations:

• two representatives from the Senate;
• two representatives from the House of Representatives;
• three representatives of local public health;
• two representatives of state public health;
• three representatives of counties;
• two representatives of cities;
• one tribal representative; and
• one representative with expertise in government finance.

 
The work group must develop a transparent process that includes opportunity for public comment.  The work group must provide recommendations to the Secretary on the system for counties to form comprehensive public health districts using existing regionalized health structures as a model by January 1, 2022.  The work group must recommend performance measures and a measure set to the Secretary by July 1, 2022.  The work group must also submit recommendations to the Legislature on adequate funding of the comprehensive public health districts, including appropriate contribution levels between cities, counties, and the state, and adequate allocation levels to sustain the public health system by January 1, 2023.
 
Department of Health Rulemaking.
The Secretary must adopt rules to provide foundational public health services through comprehensive public health districts and the DOH.  The rules must include:

• a system and process for a county or counties to create comprehensive public health districts which must serve at least 250,000 people, provide all foundational public health services, and maintain local offices in each county sufficient to meet community need;
• performance measures and proposed benchmarks to track the efficiency and effectiveness of the districts;
• a manageable measure set based on readily available data that focuses on overall performance of the system;
• a process for the DOH to certify comprehensive public health districts;
• a process to evaluate district and department performance; and
• a process for information and data to be reported by the districts to the DOH.

 
By November 1, 2024, the DOH must submit to the appropriate committees of the Legislature a report on district performance based on the identified performance measures.
 
Funding for Foundational Public Health Services.
Beginning January 1, 2023, foundational public health services funding may only be distributed to the DOH, the State Board of Health, Indian health programs, and comprehensive public health districts certified by the DOH.   Beginning January 1, 2025, and biennially thereafter, prior to allocating foundational public health funds to comprehensive public health districts, the DOH must evaluate the comprehensive public health districts' performances to satisfy the measure set established in rule.
 
Comprehensive Public Health Districts.
By January 1, 2023, counties must form comprehensive public health districts, which must be structured as required by the work group and DOH rules.  The DOH must certify the comprehensive heath districts.

Counties with a population over 1 million may be considered a comprehensive public health district without joining other counties if the county legislative authority enacts a resolution or ordinance to organize a district.  A city with a population of one hundred thousand or more and the county it is located in may establish and operate a health district.  Comprehensive public health districts consisting of two or more counties may be created when the boards of county commissioners pass a resolution establishing a district.  The district board of health must constitute the local board of health for all territory in the district and must exercise all power and all duties vested in the county board of health of any county included in the district.  Members of the district board of health are:

• one commissioner from each county represented on the district chosen by nomination from each county commission board;
• one elected city official from a larger populous city and one from a smaller populous city in the district chosen by nomination from the city;
• one tribal representative of a tribe or urban Indian health organization from within the district;
• the district health officer; and
• an equal number of seats as the total represented by county commissioners and city officials must be filled by the following individuals who are nominated and selected by the district board of health:  (1) hospital representatives from within the district; (2) licensed physicians practicing within the district; (3) licensed nurses practicing within the district; and (4) consumer representatives.

 
Comprehensive public health districts must establish a district health fund in the custody of the county treasurer.  If there are multiple counties in the district, it must be in the custody of the largest county's county treasurer.  Comprehensive public health district expenditures must be authorized by the district board of health.  Each county and city in the district must contribute towards the maintenance, operating fees, and expenses of the comprehensive public health district.
 
Comprehensive public health districts may own, construct, purchase, lease, and maintain real and personal property necessary to conduct the affairs of the district and may sell, lease, convey, or dispose of district real or personal property.
 
Employees of the district health department may be included in the personnel system or civil service and retirement plans of the city or county or a separate personnel system or civil service and retirement plan for the district health department.  The administrative officer, that acts as the executive secretary and administrative officer for the district board of health, must hold a Master or Doctor of Public Health or Public Administration, a Master of Public Policy, a Master of Business Administration, or equivalent.
 
A district advisory committee for each comprehensive public health district is established.  The comprehensive public health district must accept nominations and select diverse representatives from communities within the district experiencing health inequities.  The advisory committee must promote and facilitate communication, coordination, and collaboration among relevant local agencies, Black, indigenous, and people of color communities, persons living with disabilities, and the private sector and public sector, to address health inequities.  The advisory committee may conduct public hearings.  The advisory committee may consist of up to 15 members who may choose a chair for the advisory committee.  The members must serve two to four-year terms.
 
A city or county may withdraw from membership from a comprehensive public health district after it has been in the district for two years, but the withdrawal is not effective until approved by the Secretary.  The Secretary must determine that the withdrawal will not negatively affect the public's health and must make a final determination within 14 days of the request.  After withdrawing, a county or city must immediately seek admission in another comprehensive public health district.
 
District Health Officer.
The district board of health must submit its district health officer candidate to the Secretary.  The Secretary must determine whether the officer candidate is qualified and may appoint the officer.  A district health officer must hold a Master or Doctor of Public Health, have completed a preventative medicine residency program, and live in the district and maintain full-time residency within six months of appointment, in addition to existing requirements for local health officers which are amended to apply to district health officers.  The district health officer's salary must be paid by the DOH.
 
The district board of health may to petition the Secretary to terminate the district health officer for cause and the Secretary is authorized to remove the district health officer for cause.  Certain provisions related to local health officers, such as the notice and hearing requirements for removing a local health officer, are removed.
 
Definitions and Terminology.
"Comprehensive public health district" means all territory consisting of one or more counties organized under this chapter serving a combined population of over 250,000 people in which a district health department has capacity and resources to provide foundational public health services to all people within the territory.  Beginning January 1, 2023, generally references to "local health officer" are amended to apply to "district health officers" and references to "local boards of health" or "local health departments" are changed to "district boards of health" and "district health departments."
 
Repealed Statutes.
Statutes related to the following are repealed:

• establishing the composition of the local board of health in counties without a home rule charter;
• establishing the composition of the local board of health in home rule counties;
• requiring the DOH to develop a one-day course to train local environmental health officers, and health officers on statutory authority to grant waivers from on-site sewage system rules;
• establishing and operating city-county health departments;        
• establishing and operating health districts and district boards of health;
• establishing duties for the DOH to implement the certificate of need program, monitor health care costs, evaluate health services and utilization, and recommend strategies to encourage cost-effective services; and
• establishing a DOH study on uniform quality assurance and improvement.

Appropriation: None.

Fiscal Note: Requested on January 12, 2021.

Effective Date: The bill takes effect 90 days after adjournment of the session in which the bill is passed, except for sections 5 and 11 through 46, relating to the terminology changes to reflect the new comprehensive public health districts, which take effect on January 1, 2023.