Most health departments support an overhaul of Ky. public health system, even though some would lose state money in the process

The logo used by state and local health departments

By Melissa Patrick
Kentucky Health News

Driven by the state's pension crisis and a non-equitable funding model, Kentucky health departments warn that if the state doesn't change its requirements for how they prioritize available public health resources -- and how they are funded -- many of them will have to cut essential services, and half could close their doors.

Legislators and health-department officials are asking for a complete overhaul of the state's public health system, not only to help it survive in the face of a $40 million deficit in 2020, but also focus on core programs to improve the state's poor health outcomes.

"House Bill 129 codifies the prioritization of public health funding at every resource level -- state, local and federal -- to programs that provide the most significant opportunity to improve Kentucky's overall health," said Allison Adams, president of the Kentucky Health Department Association. "It also codifies the methodology in how that funding is distributed at the local level so that it is equitable at each county level."

The current system provides each health department with an equal amount of state funding, regardless of its ability to generate funds. The new model takes this ability into account and would distribute the state dollars accordingly, making it more equitable, said Adams. In other words, departments that have more resources would get less state funding under this model.

Using a formula that takes into account the county's population, the county's ability to support its health department based on its current taxing authority, how many employees the county would need to provide only statutory services, and an estimated increase in environmental fees, a KHDA spreadsheet shows that 14 of the 61 departments would receive less funding under this proposal. All the rest would receive more funding.

Several district health departments show the largest gains, including the Barren River District Health Department, which serves eight counties in Western Kentucky, at $1,018,200; the Lake Cumberland District Health Department, serving 10 counties in south-central Kentucky, at $1,377,842; Lincoln Trail District Health Department, serving six counties in west-central Kentucky.

The 14 departments receiving less funding include those in Breathitt, Bullitt, Clark, Fayette, Franklin, Johnson, Knox, Madison, Marshall, Montgomery, Oldham, Whitley and Woodford counties. Wedco District Health Department, which serves Harrison, Nicholas and Scott counties, is also slated for less money.

The losses range from a low of  $36,729  in Whitley County to a high of about $1 million in the Lexington-Fayette County Public Health Department.

Dr. Kraig Hambaugh, director of the Lexington-Fayette County department, cautioned that the numbers in the spreadsheet are estimates, with many of them based on assumptions. Further, he said even with the gains and losses shown in spreadsheet,  the model is designed to make sure every county's core public health needs can be met.

He also stressed that this new model is just one part of the solution to fully fund our health departments because it doesn't address their looming pension obligations. If nothing changes before July 1, he said at the current 93% projection, his department would owe about $6 million of his approximate $17 million budget to pay for retirement costs.

All that said, he recognized that his department would lose money under this new model, but said he still supported it.

"This shouldn't turn into an us versus them kind of game, one health department versus the other, because we're all part of one larger system that is designed to promote health in the commonwealth and to protect the public's health," he said.

He added that he felt HB 129 also shows the legislators and the public that local health departments are willing to do their part to economize and use their resources wisely.

Adams said the association has been talking about this new funding methodology for about five years and that association members have had opportunity to vet it. Further, she said an over-whelming majority of the departments supported the new model during a roll-call vote.

"This is a funding methodology that provides equitable resources to all of our communities so that we can provide the most basic public health services at each county level," she said.

HB 129, sponsored by Rep. Kim Moser, R-Taylor Mill, passed out of the House Health and Family Services Committee, of which she chairs, on Jan. 16 with a committee substitute. It has been recommitted to the House Appropriations & Revenue Committee. The "Public Health Transformation" bill  has 20 bipartisian sponsors.

Pension woes

This new model has been in the works for several years, but gained momentum after health department pension obligations were set to jump from 49.47 percent of payroll to the current rate of 93% of payroll on July 1, the day the next budget starts.

During a special session last summer, lawmakers gave health departments, regional universities and quasi-governmental agencies the choice of staying in the Kentucky Retirement System and paying the full obligations or leaving the system, either by paying a lump sum or buying their way out over time. Those that choose to leave would need to move employees to a 401(k)-type plan.

The departments say none of these choices are viable, and none have left KRS. The state Department for Public Health has said that without some relief from their obligations, dozens of health departments are at risk of closing.

Gov. Andy Beshear has proposed giving the departmens about $16.5 million in each year of the budget as a way to freeze their employer contribution rate at 67.41% of payroll. The Democratic governor's proposal would have to be approved by the Repubican-controlled legislature.

Lawmakers are working on another pension solution through HB 171, sponsored by Rep. Jim DuPlessis, R-Elizabethtown, which would change how health departments, regional universities and quasi-governmental agencies, pay for their pensions altogether. It would move away from the current  "percdent of pay" and move to a model that requires entities to only pay what they owe, which is often called "level dollar funding." It passed out of the House State Government Committe on Jan. 7 and is expected to be recommitted to the House Appropriations & Revenue Committee.

What is Public Health Transformation?  

The new public health model calls for health departments to only be required to provide four "core public health" areas. They include foundational public health services, which are required by law or regualtion; the Women's, Infants and Children nutrition program; the HANDS program, which stands for Health Access Nurturing Development Services for child rearing; and harm reduction and substance-use-disorder programs, including syringe exchanges.

"The programs that we've identified that are the most basic, which we call foundational services, are the programs that have been identified as comprehensive public health systems," Adams said. "So if we provide those at every level, over time we should expect better health, better health outcomes and longer life expectancies."

The plan also requires departments to perform community health assessments, which many of them already do, to determine local public health priorities beyond the core requirements. Such priorities would have to meet certain criteria for the department to address them and would also need to be funded separately.

For example, a vaccination clinic run by the Todd County Health Department  that serves only Amish and Mennonite families would be considered a local public health priority.

"It’s a niche need in Todd County that the public health department, because of strict state and federal funding guidelines, has struggled for years to fund," Alex Acquisto reports for the Lexington Herald-Leader. She notes that the program cost about $5,000 a year.

Photo: Silas Walker, Lexington Herald-Leader

The clinic serves a demographic of 3,000 that makes up one-fifth of the county's populaiton, Acquisto reports, telling of  their monthly horse and buggy trips to the clinic to get their infants and toddlers, most of whom only speak Pennsylvania Dutch, vaccinated.

The program is needed because up until a decade ago, when Jennifer Harris, the health department's director started the clinic, virtually none of the Amish or Mennonites in the area were vaccinated. Harris told Acquisto that she sees this as a clear public health need in her community because "If you have a fifth of your population who isn't vaccinated, then your whole public is at risk."

The bill also allows departments, for the first time, to refuse state program funding that their counties don't need in order to invest in the services they do need.

"Without passage of this bill in Todd County, the Amish and Mennonite and public school vaccination clinics would be some of the first services cleaved from the budget, because Harris can no longer afford them," Acquisto reports.

The bill also requires local governments to ensure a minimum ad valorum public health tax rate of at least $0.018 per $100 of assessed property value, or equivalent alternative funding, to be allocated toward foundational public health programs.

And to help offset some of the added cost, health departmetns are asking for a one year reprieve on a rule that restricts increasing environmental fees to no more than 5% each year; after that year is up, the statute would go back into place. This would allow health departments to bring those fees in line with what they actually costs, since health departments are currently subsidizing the difference.

At the committee meeting, Moser said, "So the public health transformation initiative will result in a more simplified and a more focused public health model that prevents duplication, encourages shared responsibilities and resources and expertise to create economies of scale, a fairness across the state, and clearly defines the role throughout the system."

The bill would take effect upon becoming law.