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BILL REQUEST - CODE REVISER'S OFFICE

BILL REQ. #: Z-0126.2/19 2nd draftATTY/TYPIST: KS:lelBRIEF DESCRIPTION: Concerning foundational public health services.

AN ACT Relating to foundational public health services; adding a1new section to chapter 43.70 RCW; creating a new section; and2repealing RCW 43.70.512, 43.70.514, 43.70.516, 43.70.520, and370.05.130.4

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:5

NEW SECTION. Sec. 1. (1) The legislature finds that protecting6the public's health across the state is a fundamental responsibility7of the state and this is accomplished through the governmental public8health system. This system is comprised of the state department of9health, state board of health, local health jurisdictions, and10sovereign tribal nations.11

(2)(a) The legislature intends to define a limited statewide set12of core public health services, called foundational public health13services, which the governmental public health system is responsible14for providing in a consistent and uniform way in every community in15Washington. These services are comprised of foundational programs and16cross-cutting capabilities.17

(b) These governmental public health services should be delivered18in ways that maximize the efficiency and effectiveness of the overall19system, make best use of the public health workforce and evolving20technology, and address health equity.21Code Rev/KS:lel 1 Z-0126.2/19 2nd draft

(c) Funding for the governmental public health system must be1restructured to support foundational public health services. In2restructuring, there must be efforts to both reinforce current local3public health capacity and implement new service delivery models4allowing for system stabilization and transformation.5

NEW SECTION. Sec. 2. A new section is added to chapter 43.706RCW to read as follows:7

(1) With any state funding of foundational public health8services, the state expects that measurable benefits will be realized9to the health of communities in Washington as a result of the10improved capacity of the governmental public health system.11

(2) Within the funds appropriated for foundational public health12services, the governmental public health system will begin to expand13delivery of foundational public health services in the following14areas:15

(a) Prevention and control of communicable diseases and other16notifiable conditions;17

(b) Environmental public health; and18(c) Assessment, including disease surveillance and epidemiology.19(3) Distributions to fund such foundational public health20

services or structural changes to implement such foundation public21health services must be made under allocation plans mutually agreed22to by the department, a statewide association comprised of local23public health officials, and the state board of health, and in24consultation with tribal nations.25

(4) By October 1, 2021, the department, in consultation with26local health jurisdictions, sovereign tribal nations, and the state27board of health, shall report on:28

(a) New service delivery models, and a plan for further29implementation of successful models;30

(b) Changes in capacity of the governmental public health system;31and32

(c) Progress made to improve health outcomes.33(5) For purposes of this section:34(a) "Foundational public health services" means a limited35

statewide set of defined public health services within the following36areas:37

(i) Control of communicable diseases and other notifiable38conditions;39Code Rev/KS:lel 2 Z-0126.2/19 2nd draft

(ii) Chronic disease and injury prevention;1(iii) Environmental public health;2(iv) Maternal, child, and family health;3(v) Access to and linkage with medical, oral, and behavioral4

health services;5(vi) Vital records; and6(vii) Cross-cutting capabilities, including:7(A) Assessing the health of populations;8(B) Public health emergency planning;9(C) Communications;10(D) Policy development and support;11(E) Community partnership development; and12(F) Business competencies.13(b) "Governmental public health system" means the state14

department of health, state board of health, local health15jurisdictions, and the sovereign tribal nations of Washington.16

(c) "Local health jurisdictions" means a public health agency17organized under chapter 70.05, 70.08, or 70.46 RCW.18

(d) "Service delivery models" means a systematic sharing of19resources and function among state and local governmental public20health entities and sovereign tribal nations to increase capacity and21improve efficiency and effectiveness.22

NEW SECTION. Sec. 3. The following acts or parts of acts are23each repealed:24

(1) RCW 43.70.512 (Public health—Required measurable outcomes)25and 2007 c 259 s 60;26

(2) RCW 43.70.514 (Public health—Definitions) and 2007 c 259 s2761;28

(3) RCW 43.70.516 (Public health—Department's duties) and 2007 c29259 s 62;30

(4) RCW 43.70.520 (Public health services improvement plan—31Performance measures) and 2007 c 259 s 64 & 1993 c 492 s 467; and32

(5) RCW 70.05.130 (Expenses of state, health district, or county33in enforcing health laws and rules—Payment by county) and 1993 c 49234s 242, 1991 c 3 s 313, 1979 c 141 s 84, & 1967 ex.s. c 51 s 18.35

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Code Rev/KS:lel 3 Z-0126.2/19 2nd draft

2019-21 Biennium BudgetDecision Package

Agency: 303 - Department of HealthDecision Package Code-Title: 1A - Fund Founda onal Public HealthBudget Session: 2019-21 RegularBudget Level: Policy LevelContact Info: Ryan Black

(360) [email protected]

Agency Recommendation SummaryThe local, tribal, and state governmental public health system is failing to provide the most basic, core publichealth services necessary to adequately protect and promote the health of all Washingtonians. Thisproposal takes a phased approach to fully funding the Founda onal Public Health Services gaps ($450million/biennium), star ng with funding communicable disease, environmental public health andassessment services. The outcomes include reducing communicable disease and environmental healththreats.

Fiscal SummaryDollars in Thousands

Opera ng Expenditures FY 2020 FY 2021 FY 2022 FY 2023

Fund 001 - 1 $148,421 $147,580 $147,580 $147,580

Total Expenditures $148,421 $147,580 $147,580 $147,580

Biennial Totals $296,001 $295,160

Object of Expenditure FY 2020 FY 2021 FY 2022 FY 2023

Obj. N $148,421 $147,580 $147,580 $147,580

Package DescriptionProblem Statement:

The local, tribal, and state governmental public health system is failing to provide the most basic, core publichealth services necessary to adequately protect and promote the health of all Washingtonians. This makesall Washingtonians vulnerable to communicable diseases (both new and old), environmental health threats,chronic diseases (diabetes, heart disease, stroke, and cancer), and unhealthy births and childhoods. Theresults of a deteriora ng public health system are increased health care costs, reduced produc vity in oureconomy, and needless suffering from preventable disease and death.

https://abs.ofm.wa.gov/budget/2019-21/R/303/versions/20/decision-pack...

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The crux of the ma er is a lack of funding to keep up with a growing demand for public health services dueto increased popula on sizes, resurgent and new health threats, the general costs of “doing business,” andjust trying to keep up with “pu ng out fires” rather than focusing on preven on.

The Legislature, Execu ve Branch, local government, and many others have been aware of this challenge foryears. Studies and small, brief infusions of funds to the governmental public health system have been madeover the past decade or so. But all have been inadequate and much of the funding increases were short-lived given the challenges of the Great Recession, demands from McCleary, and behavioral health systemchallenges.

The public health system in Washington State has iden fied what are founda onal public health services(FPHS) that need to be everywhere in order for them to work anywhere. Our work has been in sync with asimilar na onal effort, and in fact has informed much of that work.

Having iden fied the FPHS, the Legislature authorized funding for this biennium to assess the local and statesystem’s capacity to provide those services and to iden fy the funding gap to fully provide the servicesacross the state. That assessment occurred last winter/spring and found:

No FPHS is fully or significantly implemented across all health departments. The gaps are not uniform, that is there is no consistency in gaps for the larger or small healthdepartments, no consistency in urban or rural health departments.Every health department has significant gaps.The biennium funding gap to fully fund the founda onal public health services is $450 million.

Without new funding to address cri cal gaps, risks to the public include:

• Con nued program and service cuts, impac ng response me and ability to work proac vely. It takeslonger to inves gate – and stop – outbreaks of foodborne illness because of increased complexity of thediseases and program cuts.

• Limited response capacity for all hazard emergencies such as fires, earthquakes and floods.

• Diminished ability to prevent and respond to public health threats, including measles and Hepa sC.

• Lessened a en on on improving immuniza on rates of children and adults pu ng communi es atrisk for the spread of diseases like whooping cough, measles and influenza.

• Decreased partnership opportuni es with school districts (including safety inspec ons), nonprofitsand local agencies.


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• Limited ability to collect and share cri cal health informa on with the public.

• Limited ability to enact policy to protect communi es and prevent adverse health outcomes.

• Reduced capacity to train staff on drug resistant TB, foodborne outbreaks, lead poisoning, safedrinking water systems and other public health threats.

• Diminished ability to fill cri cal public health posi ons. Open nursing posi ons go for monthswithout applicants.

What is your proposed solu on?

In response to the public health crisis, local, state and Tribal public health officials and leaders have cometogether to propose a collabora ve and comprehensive approach that has culminated in this joint decisionpackage represen ng the en rety of the public health system.

Understanding that funding the en re FPHS gap of $450 million/biennium is a tall order, our proposedsolu on uses a phased approach, star ng with funding a subset of the FPHS this biennium and having thatfunding added to the Department’s baseline budget. Then, in the next biennium, adding another subset ofFPHS and including that in the Department’s baseline budget, and repea ng that process un l full funding isachieved.

This decision package starts with what we believe to be the most cri cal “fund first” FPHS: communicabledisease and environmental health services, the capabili es that support them, and assessment services(e.g., epidemiology, community health assessments).From the 2018 FPHS assessment, the es matedaddi onal funds needed to fully implement this subset of services is $295M/biennium.

To ensure the most cost-effec ve and efficient service delivery, we propose to build on the three innova vepilot projects funded this year from the $12 million, one- me funding the legislature appropriated for FPHS.Therefore the proposed investment relies heavily on transforming the public health system by looking athow services are currently provided and developing new models for how to deliver them.This proposalincludes funding for both innova ve new service delivery models and reinforcing capacity.

It is important to note that the Tribes are engaging in a Tribally-led, culturally appropriate process to iden fyTribal Founda onal Public Health Services and iden fy their funding gaps and available revenues. For thisdecision package, $1.2 million is being requested for Tribes as follows:


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$1M – Funding to the Tribal Epi Centers (UrbanIndian Health Ins tute and NW TribalEpidemiology Center) for disease surveillance andassis ng Indian tribes, tribal organiza ons, andurban Indian communi es to promote publichealth.

$200K – AIHC Partnership Development – tocoordinate tribal engagement in founda onalpublic health services collabora ve demonstra onprojects with DOH, SBOH, and/or LHJs in the areasof policy development for emergencypreparedness response and communicable disease

control across jurisdic ons.

A breakdown of the budget request is provided in Table 1.

Table 1.

A detailed inventory of the specific FPHS investments has been a ached to this decision package.

Addi onal Background

What is the governmental public health system?

The four broad en es include:

State Board of Health (SBOH), which is separate from the State Department of Health (DOH) and isresponsible for developing public health policy and regula onsDOH led by the Secretary of Health who is appointed by the GovernorIn Washington there are 35 locally governed local health jurisdic ons represen ng 39 coun es.Tribes of which there are 29 federally recognized and sovereign tribal na ons.


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Each of these organiza ons work hard every day to protect and improve the health of our communi es.These agencies are responsible for working together to implement the FPHS. That’s not to say that otheragencies and community partners aren’t part of the larger public health system – far from it and in fact ourgovernmental public health system relies heavily on these partners for many programs and services beyondthe FPHS.

What are Founda onal Public Health Services?

Founda onal Public Health Services (FPHS) are a limited and defined set of core ac vi es within 6 programsand 6 capabili es that must be present everywhere in Washington in order for them to work anywhere. FPHS are services that primarily or only government provides, everywhere, are popula on-based services(versus individual services) that are focused on preven on, and; in many cases are mandated by federal orstate laws.

Founda onal Programs include:

Communicable Disease ControlEnvironmental Public Health ServicesChronic Disease and Injury Preven onMaternal and Child Family HealthAccess to Clinical CareVital records (birth and death cer ficates)

Founda onal Capabili es include:

Assessment (disease surveillance and epidemiology)Emergency Preparedness and Response (all hazards) Communica onsCommunity Partnership and DevelopmentBusiness Competencies

The 5 Guiding Principles of Public Health Transforma on

There is a limited statewide set of core public health services, called Founda onal Public HealthServices (FPHS), that government is responsible for providing.

1.

Core public health services are funded through dedicated revenues that are predictable, reliable andsustainable, and responsive to changes in demand and cost over me.

2.


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Governmental public health services are delivered in ways that maximize the efficiency andeffec veness of the overall system.

3.

Governmental public health ac vi es are tracked and performance is evaluated using evidence-basedmeasures.

4.

Local revenue genera ng op ons are provided to address locally driven priori es that are targeted tospecific community problems.

5.

What has been done already?

During the 2017 – 19 biennium, a one- me investment of $12 million was appropriated to founda onalpublic health services with a focus on communicable disease. The investment has allowed the public healthsystem to:

Conduct disease surveillance and inves ga ons where resources were not able to keep up with thedemand or maintain resources which were at risk of losing. In some areas, being able to proac velyinves gate all case reports rather than having to priori ze which cases to pursue which has risks.Other areas, were be er prepared when an inves ga on response was necessary, improving response

me and further reducing the spread of the disease.

Begin to address backlogs in communicable disease reports to stop the spread of disease.

Maintain and expand public health laboratory services which are essen al for our communi es in thetracking, repor ng and monitoring of communicable diseases

Resources to support data consolida on.

Shared service demonstra on projects were piloted:Tuberculosis preven on and control exper se, technical assistance, coordina on and a responseteam to all LHJs, statewide. Epidemiology and community health assessment exper se to mul ple LHJs in EasternWashington. Exper se and technical assistance to LHJs in making mely informa on available to health careproviders in their communi es.

Why is public health selec ng communicable disease, environmental public health and assessment as


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“fund first?”

To build on the 2017-2019 ini al one me investment of $12M for communicable disease andreinforce the capacity that has begun with these funds.Because stopping and preven ng the spread of disease whether from one person to another and fromthe environment to people has an immediate and long-term impact on individuals, communi es, thehealthcare system, schools, work places, business, and tourismBecause many laws and regula ons currently exist in Washington regarding public health’s role incommunicable disease and environmental public health – but they are largely unfunded mandates.Because collec ng, analyzing, sharing and using data is essen al to providing individuals andcommuni es the informa on they need to make good health choices and help public healthprofessionals and policy makers know if the services are making a difference.

Other suppor ng materials (ATTACHED)

Inventory of FPHS proposed investmentsBackup material for specific investment are available upon request

Assumptions and Calculations

Expansion or altera on of a current program or service:


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This request is to con nue the 2017—2019 one- me funding of $12 million for Communicable Diseaseservices provided across the state and to request addi onal resources to further fund communicabledisease services, environmental health services, and assessment (disease surveillance andepidemiology).

A summary of the 2017-19 investments is provided in Table 2.

Table 2.

Detailed assump ons and calcula ons:See a ached inventory of FPHS investments for expenditure es mates and assump ons.

Workforce Assump ons:See a ached documents.

Strategic and Performance Outcomes

Strategic framework:Goal 1: Access & Success – Providing every Washingtonian a world-class educa on that prepares him orher for a healthy and produc ve life, including success in a job or career, in the community and as alifelong learner.

Children need to be healthy in order to learn.Preven ng diseases through immuniza on and safe foodprac ces are two examples of the impact of the public health system in ensuring that children are readyto learn. In addi on, lead tes ng to make sure water is safe to drink and homes and schools are safefrom contamina on is an important public health strategy.


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Goal 2: Business Vitality – Washington is a great place to grow your business

A responsive and viable public health system is essen al for healthy and economically vital communi esacross Washington The public health system monitors and responds to communicable disease outbreaksand works to prevent chronic disease. The health of employees directly impacts the place where theywork – employees that call in sick due to preventable illnesses impact the produc vity of the business. Keeping employees healthy helps reduces health care expenditures for both the employee andbusiness. Caring for sick children also impacts the produc vity of the business when parents need totake me off to care for them.

Goal 3: Sustainable energy & a clean environment – Keep our land, water and air clean

The public health system is responsible for ensuring water is safe to drink and regulates all publicdrinking water systems in the state to ensure that people don’t get sick.

Goal 4: Healthy & Safe Communi es – Safe People – Help keep people safe in their homes, on their jobsand in their communi es

The public health system is responsible for monitoring and responding to communicable diseaseoutbreaks. The ability to achieve this goal is dependent on the capacity and exper se across the state torespond to illness reports and take appropriate ac ons to control the spread of disease.

An investment in communicable disease preven on and control and environmental public health willprovide the capacity to communi es who lack this ability to measure the success of this goal. 2.2:Decrease incidents of food-borne illnesses by 5% from the 2012 baseline by 2020. The ability to achievethis goal is dependent on the public health system’s capacity to respond to illness reports and takeappropriate ac ons to control the spread of disease.

Goal 5: Efficient, effec ve and accountability government - Transparency and Accountability – I knowhow my money is being spent.

The new service delivery models will use a new framework that will allow mul ple jurisdic ons to sharestaff and services without the need for someone to be physically present in every loca on to provide theFPHS. These will be targeted towards providing capacity and exper se for tribal na ons and LHJ’s thatdon’t have adequate resources to do this cri cal work now. This is expected to result in increasedefficiency and effec veness in the delivery of services in the public health system.


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Based on public health transforma on guiding principles “Governmental public health services shouldbe delivered in ways that maximize the efficiency and effec veness of the overall system,” workgroups ofsubject ma er experts from local and state public health are designing new / innova ve service deliverymodels that:

Apply learning from past experiences with “shared services” and na onal informa on about crossjurisdic onal sharing (CJS)

1.

Apply earnings from the three shared service demonstra on projects funded with a por on of theone- me 2017-2019 ini al investment

2.

Use the 2016 WSALPHO Service Delivery Model Con nuum and evaluates whether the servicerequires “on-the-ground” staff (e.g. engaging with communi es so they priori ze health needsand plan the response; inspec ng a sep c system) or can be accomplished from a distance (e.g.data analysis; following up with a communicable disease client by phone; directly observedtherapy for TB clients via skype)

3.

Use data on the distribu on of disease or other focus of the specific service (e.g. immuniza onproviders, schools or restaurants to be inspected)

4.

Use data from the 2018 FPHS Assessment regarding gaps in capacity vs. exper se and currentsharing, wiliness to share, and level of local exper se needed for various services

5.

Use standardized es mates of workload to FTE6. Implement best prac ces uniformly statewide7. Creates the best mix of local presence / local exper se and specialized subject ma er exper se forthe most effec ve, efficient and equitable delivery of FPHS everywhere in Washington – with thefunds available

8.

Performance outcomes:See a ached inventory of FPHS investments for performance measure assump ons.

Other Collateral Connections

Intergovernmental:This proposal will provide capacity to address cri cal public health problems in communi es withinadequate resources.

This proposal supports the Healthier Washington ini a ve and brings public health resources andknowledge to the planning/coordina on groups. It also supports the work of DEL and OSPI to ensurechildren are healthy and ready to learn and supports the work of HCA in preven ng and controllingcommunicable diseases. DSHS in behavioral and mental health planning and program implementa on.

Stakeholder response:All ci zens of Washington are affected by this proposal. However, the primary stakeholders directlyaffected by this proposal are government en es and non-governmental community based


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organiza ons. The department an cipates broad support from these stakeholders as this proposalrepresents a significant investment in these en es and their respec ve missions.

Legal or administra ve mandates:None

Changes from current law:There are no changes requested to current law for this proposal.

State workforce impacts:Not applicable

State facili es impacts:Not applicable

Puget Sound recovery:Not applicable

Agency Questions

Did you include cost models and backup assump ons?Assumed...funded!

Reference DocumentsAssessment Performance Measures.pdfCommunicable Performance Measures.pdfEnvironmental Performance Measures.pdfFPHS Inventory.pdfFPHS_ITaddendum2019-21_Dra -Final.docx

IT Addendum

Does this Decision Package include funding for any IT-related costs, including hardware, so ware,(including cloud-based services), contracts or IT staff?YesFPHS_ITaddendum2019-21_Dra -Final.docx


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