Background:

Structure of the Public Health System.

"Public health" is defined by statute as the activities that society does collectively to assure the conditions in which people can be healthy. The public health system in Washington includes the Department of Health (Department), the State Board of Health (Board), 35 local health jurisdictions, and tribal governments.

The Department is charged with: performing duties related to vital statistics; studying factors related to health improvement, the causes of morbidity and mortality, and the effects of the environment on public health; investigating and advising local health officers; performing health inspections; regulating public water systems; and maintaining a public health laboratory.
The 10-member Board provides a public forum for the development of public health policy. Rules adopted by the Board cover issues such as newborn screening, childhood immunizations, disease prevention and control, cleanliness of facilities, drinking water quality, food service, and vital statistics.
Local health jurisdictions (county health departments, multi-county health districts, and city-county health departments) enforce public health statutes, as well as rules adopted by the Board and the Department, and local governments. Local health jurisdictions are governed by a board of health.
The state, tribes, and urban Indian health clinics address public health issues through a government-to-government relationship.

Protecting the public's health across the state is recognized in statute as a fundamental responsibility of the state. Distributions to local health jurisdictions must deliver certain outcomes, such as a reduction in vaccine preventable diseases and the creation of a disease response system capable of responding at all times.

Public Health Services Improvement Plan.

The Department is required to submit a biennial public health services improvement plan developed in coordination with the Board, local health jurisdictions, and others. The plan addresses minimum standards for public health protection, strategies and a schedule for improving public health programs throughout the state, and a recommended level of dedicated funding.

Core Public Health Functions of Statewide Significance.

In 2008 the Department was required to develop a prioritized list of activities and services performed by local health jurisdictions that qualify as "core public health functions of statewide significance" and to adopt performance measures. The Department and local health jurisdictions must abide by the list and performance measures. The Department provides local jurisdictions with financial incentives to encourage local investments in core public health functions. Local jurisdictions may not supplant existing local funding with those state resources. "Core public health functions of statewide significance" are health services that: (1) promote uniformity in public health activities, increase the system's strength, or apply to broad public health efforts; (2) if inadequately addressed, are likely to have a significant adverse impact beyond the borders of the local health jurisdiction; and (3) address communicable diseases, public health emergencies, chronic diseases and disabilities, promotion of healthy families and the development of children, environmental health concerns, and assessment of local health risks and trends.

2016 Operating Budget.

The 2016 Supplemental Operating Budget directed the Department and local health jurisdictions to provide a proposal outlining a plan for implementing foundational public health services statewide to modernize, streamline, and fund a twenty-first century public health system.

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Summary of Bill:

Governmental Public Health Improvement Plan and Shared Services.

Protecting the public's health is recognized as a fundamental responsibility of the state that is accomplished in collaboration with local health jurisdictions and sovereign tribal nations. Within funds appropriated, local health jurisdictions and the Department of Health (Department) must expand delivery of shared services to modernize and streamline the governmental public health system. The expansion must begin with a shared services project for epidemiology assessment and communicable disease monitoring and response.

By October 1, 2018, the Department shall develop a governmental public health improvement plan. At a minimum, the plan must include:

activities and services that qualify as foundational public health services;
an assessment of current capacity, unmet needs, and service delivery models to provide foundational public health services;
statewide models for shared services and a plan for further implementation;
a comprehensive accountability structure, including performance measures;
the cost of providing foundational public health services statewide, including the cost of improved service delivery models;
a funding allocation model to ensure services are provided across the state; and
recommended schedules for periodic updates, evaluations, assessments, and reporting progress.

The Department must develop the improvement plan in consultation with: local health jurisdictions; the State Board of Health (Board); the Washington State Association of Local Public Health Officials; individuals or entities with expertise in the development of performance measures, accountability, and systems management, and experts in the development of evidence-based public health or medical practice guidelines; and those who will be impacted by such performance measures.

The performance measures must meet certain goals and be developed to ensure foundational public health services are available statewide. The measures must: reflect best scientific evidence, national standards of performance, and innovations in governmental public health; establish the levels of performance needed to achieve core public health services delivery for each local health jurisdiction and the Department; and describe the resources necessary to meet the performance levels.

The current law requiring development of a public health services improvement plan is repealed.

Definitions.

"Core or foundational public health services" are defined as essential capabilities and core programs that must be present in every community through the governmental public health system to effectively and efficiently protect and promote healthy individuals, families, and communities throughout the state and:

are population-based prevention services or individual interventions that have significant population health implications;
require a consistent and uniform level of services throughout all communities to protect the population;
have governmental public health as the only or primary service provider; or
provide the necessary organizational capabilities to support program services.

"Core programs" are public health programs needed in every community to protect people's health, including: control of communicable disease 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 care services; and vital records. "Essential capabilities" means the knowledge, skill, ability, and systems infrastructure necessary to support effective and efficient governmental public health services, including: assessing the health of populations through surveillance and epidemiology; public health emergency planning; communication; policy development and support; community partnership development; and business competencies. "Governmental public health system" means the Department, the Board, local public health agencies and boards, and sovereign tribal nations. "Shared services" means a systematic sharing of resources and functions among state and local governmental public health entities and sovereign tribal nations to increase capacity and improve efficiency and effectiveness.

Core Public Health Services Account.

Receipts from moneys appropriated for foundational public health services must be deposited into the Core Public Health Services Account, which is created in the State Treasury. The Department shall make distributions under allocation plans mutually agreed to by the Department and local health jurisdictions.

Staff Summary of Public Testimony:

(In support) Medical care focuses on individual cases, and public health focuses on prevention, monitoring, and responses to outbreaks for the entire community. When a disease outbreak begins, public health tracks individual cases, reaches out to people who have come into contact with infected persons, puts out alerts, and works with hospitals, clinics, and schools to prevent further spread of the disease. Without public health, there will be more of those illnesses, patients will fill hospitals, and sick children will miss school.

This bill creates a new vision for a twenty-first century public health system to improve the health of families and communities. It updates the list of core public health programs and capabilities and requires development of a public health improvement plan that will contain all the components necessary to modernize the public health system. It also directs public health to increase efficiency, including with shared services, and creates an account for any amounts appropriated. There will be joint accountability for the work of the Department of Health and local health jurisdictions. Local health jurisdictions are very excited to work on shared services.

Public health is at a breaking point. Public health funding has decreased over the last few years, and it has had a huge impact on public health departments. The public has come to expect certain government services, like investigation of foodborne and waterborne illnesses and public health emergency response. These services cannot be supported with a user fee, and public health does not have taxing authority. Small, large, urban, and rural communities are all challenged by cuts to staffing because of lack of funding. This bill is critical to the sustained operation of rural health departments. It is critical to have a uniform level of services and protection across the state.

Public health is critical in the fight against communicable diseases, like tuberculosis, Zika, mumps, Legionella, and influenza. Mumps has emerged in several counties, and it can have devastating consequences. A whooping cough epidemic is likely to occur again. The rates for sexually transmitted infections are higher than they have been in 20 years, but responding requires a lot of resources. Pierce County had to cut its zoonotics program for lack of funding, which impacts Ebola, Zika, and West Nile viruses. Immunization rates throughout the state are low, but public health does not have adequate resources to work with schools to improve rates. This bill would also provide an investment in decreasing chronic disease and injury prevention.

(Opposed) None.

Staff Summary of Public Testimony:

(In support) Washington's public health system is in crisis and needs help. In the past five years, the Department of Health has taken up the task of rebuilding the modern public health system. This bill creates an account so that the public health system will have a dedicated place for the funding. The development of the two demonstration projects will increase efficiency in the way that public health services are delivered. The plan required under the bill will contain all of the components needed for a modern system. Great progress is being made through this collaborative process. In the last 10 years, staff levels in small rural health jurisdictions have decreased significantly. These jurisdictions have lost the ability to recruit, train, and retain qualified staff. Their capacity to deal with public health emergencies has been reduced. This legislation is the first step in stabilizing a system that is suffering a crisis. In many ways, we already deliver the kinds of services addressed by the shared demonstration projects, but public health delivery will look different in every county. The smallest and most vulnerable jurisdictions must be maintained. Public health is essential. The most recent flu season was very serious, and we are in the middle of a mumps epidemic. There are multiple reported cases of drug resistant tuberculosis, and the current levels of syphilis infections are higher than they have been for decades. The public health safety net is frayed, and public health funding has dropped significantly.

(Opposed) A line between impersonalized mandates and a personal decision must be maintained. The money put into the project under this bill could cross this line. The majority of patients with mumps have been vaccinated. Immunization rates throughout the state are not low; almost 97 percent are not exempt from vaccination. The outbreak of mumps is a vaccine failure. The money for this bill is better spent elsewhere until the quality of vaccines is improved. The money is better spent on addressing drinking water in public schools.