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 (State 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 local public health jurisdiction is governed by a local board of health (board), the membership of which depends on whether the county is a home rule county or part of a local health district. For example, in home rule counties, the membership of the board is governed by the county charter. Elected officials from cities and towns in the county may be appointed to the board. The board may also include individuals who are not elected officials, but such individuals may not constitute a majority of the board. In nonhome rule counties that are not part of a local health district, the county's board of commissioners constitutes the board. The county may expand the membership of the board to include elected officials from cities or towns. The board may also include individuals who are not elected officials, but such individuals may not constitute a majority of the board.
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 State 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 State 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.
A work group is established to develop and recommend to the State Board of Health (State Board) a public health system to provide foundational public health services through local health jurisdictions, comprehensive health services districts, and the Department of Health (DOH). The work group consists of the following members appointed by the Governor to represent diverse geographic locations:
The work group must develop a transparent process that includes opportunity for public comment. The work group must provide recommendations to the State Board on the system for counties to form comprehensive health services districts by July 1, 2022. The work group must recommend performance measures and a measure set to the State Board by January 1, 2023. The work group must also submit recommendations to the Legislature on adequate funding of local health jurisdictions and comprehensive health services districts by July 1, 2023.
State Board of Health Rulemaking.
The State Board must adopt rules to provide foundational public health services through local health jurisdictions, comprehensive health services districts, and the DOH. The rules must include:
By November 1, 2024, the State Board must submit to the appropriate committees of the Legislature a report on local health jurisdiction and comprehensive health services district performance based on the identified performance measures.
Funding for Foundational Public Health Services.
Beginning January 1, 2024, comprehensive health services districts are included in the foundational public health services process so that 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, the comprehensive health services districts, and the State Board, to the OFM that there has been an agreement on the distribution and uses of state foundational public health services funding. Beginning January 1, 2027, and biennially thereafter, prior to allocating foundational public health funds to comprehensive health services districts, the DOH must evaluate the comprehensive health services districts' performances to satisfy the measure set established in rule.
Comprehensive Health Services Districts.
By January 1, 2024, counties must form comprehensive health services districts. The DOH must certify the comprehensive health services districts. Nine comprehensive health services districts are established and consist of the following counties:
Counties with a population over 800,000 may be considered a comprehensive health services district without joining with other counties when the county legislative authority of the county passes a resolution or ordinance to organize such a comprehensive health services district.
Comprehensive health services districts are formed to help diversify and stabilize funding services for public health. Comprehensive health services districts are established to encourage the systemic sharing of resources and functions among state and local governmental public health entities, sovereign tribal nations, and Indian health programs to increase capacity and improve efficiency and effectiveness. Comprehensive health services districts must:
Members of the comprehensive health services district board of health are:
City and county elected officials may not constitute a majority of the board. The Governor-appointed members may serve three-year terms and may serve two terms. The board may establish its own bylaws.
Comprehensive health services districts must establish a district health fund in the custody of the county treasurer where the headquarters office of the district is located. Comprehensive health services district expenditures must be authorized by the district board of health.
Each comprehensive health services district must have an administrative officer who is an employee of the comprehensive health services district and is responsible for administering the operations of the district. The administrative officer's salary must be paid by the DOH. Comprehensive health services 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.
Beginning January 1, 2024, comprehensive health services districts must pay for expenses incurred by the health district or county for carrying out provisions of public health laws, rules, and enforcing proclamations of the Governor during a public health emergency.
District Health Officer.
Within the DOH the position of regional health officer is created. The Secretary of Health must appoint six regional health officers, who are each assigned to a comprehensive health services district.
Local Boards of Health.
Each local board of health must include a tribal appointee selected by the Indian Health Board and members from the following categories (who may not be elected) in addition to existing members of the local board of health:
If the number of board members selected from these three categories is evenly divisible by three, there must be an equal number of members selected from each of the three categories. If the number of board members selected from these categories are not evenly divisible by three, there must be an equal number of members selected from each of the three categories up to the nearest multiple of three. The number of city and county elected officials on the board of health may not constitute a majority of the board. Any decision by the board of health related to the setting or modification of permit, licensing, and application fees may only be determined by the city and county elected officials on the local board of health.
Changes to Public Health Governance.
A county may not make a material change to its public health structure unless:
Before making a material change to the county's public health governance structure, the county legislative authority must: provide notice and a meaningful opportunity for the public to comment on the material change; participate in a good faith mediation process with any affected county, city, or town that objects to the material change; and approve the material change by a majority vote of the county legislative authority taken in an open meeting. The material change may not go into effect less than 12 months after the vote of the county legislative authority.
A material change to a county's public health governance structure includes joining or withdrawing from a local health district; entering or terminating an agreement for a combined city-county health department; or amending the county charter or enacting an ordinance altering the composition of the local board of health.
If a county does not comply with these requirements, the State Board must issue a preliminary notice of violation to the county, which the county must cure within 30 calendar days. If the county fails to cure the violation within 30 days, the State Board must issue a final notice of violation to the county and send a copy of the final notice to the State Treasurer. Upon notification to the State Treasurer, the State Treasurer must cease all future distributions from the Dedicated Marijuana Account or the Liquor Excise Tax Fund. The provisions relating to the material change to a county's public health governance expire on January 1, 2024.
Statutes related to establishing a DOH study on uniform quality assurance and improvement are repealed.
The substitute bill:
(In support) The Legislature has continually underfunded public health and we must determine adequate funding. Everyone deserves to have access to equitable health services and that is not happening in Washington right now, which has become even more apparent during the pandemic. The pandemic has given us an opportunity to strengthen our public health system. Washington has done some great work to ensure the system is responding to the pandemic and the intent of this bill is to continue this work.
This year, we have throughout the state seen what happens when politics are involved in public health. Communities must base public health decisions on science and what is best for the community, not politics. Seventeen local health officers have left, retired, were forced out, or resigned in protest due to the politicization of public health. This bill protects the implementation of evidence-based public health practice. The Department of Health (DOH) has provided support to 23 counties for contract tracing and has provided other management roles because local health jurisdictions could not. Consistency and efficiency across the public health system are important, as is bringing in more voices to the public health decision-making process. This year the Legislature is proposing to fund public health at a substantial level, which paired with regionalization would have a substantial impact.
There has been lots of work done already, but there is still much to do. This bill is a reimagination of how we address public health which is long overdue.
Financing foundational public health is the most important aspect of the bill. The public health system is chronically underfunded. We need to find efficiencies and protect the public health system. Regionalization of public health is a good idea and something that is done in other areas of health care.
The absolute independence of the health officer is critical. Currently many local boards of health have no experience in health or public health. Changing the composition of the boards to provide a better balance is necessary, though the categories found in House Bill 1110 are an improvement with the inclusion of the tribal representative and health officer.
The voices of those who are impacted by health inequities need to be included in the public health system. This bill allows for a refocusing and bringing others aboard to shine a light on the invisible barriers of health inequities. When leaders make decisions without considering impacts on health and equity the community suffers. We cannot continue to allow politicians to censor public health.
(Opposed) This bill takes away local control. Local health jurisdictions are an integral part of home building and have responsibilities to approve sewer, septic, and water systems. These decisions should be kept at the local level.
The funding for this bill and the public health system comes out of the pockets of taxpayers. This bill creates a government authority that is not responsible to taxpayers, it is taxation without representation.
This bill will kneecap local decision makers. It is confusing as to how making these districts larger will help. Instead it will undermine the trust people have in their local health boards.
(Other) There are many concerns about this major revision to the public health system. The designation of the district health officer as a state employee creates a presumption that the appointment and oversight is linked to the state. This bill shifts the focus from local to regional concerns and raises the question of whether district health officers will have the autonomy to make local decisions or if the direction would come from the state.
Moving from local districts to larger regional jurisdictions will have a negative effect on communities. Currently there are natural interconnected relationships, which may be lost along with local decision making. There is also concern about losing the community support if the local health jurisdiction becomes just a part of a larger district. Local public health has never been more important, and this bill may diminish the positive impacts local public health has on local communities at the time they need public health support most.
People are dying because of bad decisions made by politicians that have no background in health. We need health care and public health professionals making these decisions, not politicians.
The Foundational Public Health Services Steering Committee has been working for many years. The state has invested in this committee and process and it already includes the entire public health system. The foundational public health system has already put together a system of shared services, which are critical.
The pandemic has taught us a lot about our public health system, both where we excel and where we need improvement. It has stretched the public health system. We should be using lessons learned to inform future conversations. Planning to restructure the entire system during a pandemic is not reasonable, is unfair, and takes time away from critical work to fight the pandemic.
Many decisions in health care are made by people who only have the administrative and financial outlook in mind. Doctors do not have the equipment they need, and staff do not have the training they need. Family members are dying because local hospitals do not have the necessary equipment and other families should not have to go through this loss.
The Appropriations Committee recommended the addition of a provision, making sections of the act related to the establishment of the comprehensive health services districts null and void if sufficient funding for those provisions is not provided by June 30, 2022.
(In support) The COVID-19 pandemic has exposed the vulnerabilities and limitations of the public health system. The comprehensive health services districts would build on foundational public health models that would increase efficiencies and consistencies in the health system. Necessary resources must be provided. There is a lack of expertise and lived experience in the composition of local boards of health, and it has led to negative impacts during the pandemic. Communities need people who understand and speak to social and economic differences. Decisions will be decided by science.
(Other) Local jurisdictions understand the importance of collaboration. The regionalization of the comprehensive health services districts creates another layer of government that can inhibit communications. None of the current foundational public health reports call for the creation of comprehensive districts. Adequate funding for public health is needed.