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<p>In a time of constant change and budget cuts, directors of North Carolina’s local health departments ponder how they’ll maintain public health services.

By Rose Hoban

At the annual meeting of North Carolina’s state health directors last week in Raleigh, small knots of people gathered in the halls and the backs of conference rooms, all discussing the same question: How will public health survive the coming changes in health care financing?

One of the biggest concerns voiced by health directors both off and on the record centered around the future of North Carolina’s Medicaid program. Currently, legislators are discussing changing both how the program gets administered and how services get paid for. And for many local health departments, Medicaid payments – small as they are – are key to keeping budgets solvent.

DHHS Sec. Aldona Wos. Photo credit: Rose Hoban (file photo)

“About one-third of the clients seen in local health departments statewide are Medicaid patients,” said Jim Bruckner, the health director from Macon County. He said the other two-thirds of patients who come into health departments for immunizations, treatment for sexually transmitted infections, reproductive health care and, in many counties, primary care services, are uninsured.

While Medicaid reimbursement alone can’t pay all the bills, Bruckner said those dollars are vital. He explained that departmental infrastructure and nurses’ salaries are built on the foundation of Medicaid reimbursement.

“When we do have outbreaks, like when we deal with pertussis or we deal with Ebola threats, and all those other issues in our communities, when we provide all those other services, Medicaid did contribute in some way to the other activities,” he said.

State Health and Human Services Sec. Aldona Wos praised the work done by public health personnel during an address to the group on Thursday morning.

“We are very fortunate in this state to have a world-class public health network,” Wos said. “When we are well trained, when we are hard working, when we are passionate, actually, our communities become safer and the citizens in our state become and remain healthier.”

But health directors didn’t get much solace from Wos when it came to ensuring state funding. She said that as her department worked to reform Medicaid, her aim was to “do no harm” to public health.

But it’s not clear how public health departments would fit into the Medicaid arrangements being debated in Raleigh, whether state lawmakers decide to shift the program to accountable care organizations or to managed care.

“We’re taking into consideration what we and everyone else knows is on the ground,” Wos said later. “It’s not a situation where we try to fix one part and all of a sudden the other part breaks apart.”

Unfunded mandates

According to the National Association of County and City Health Officials, health departments across the country have lost more than 44,000 jobs since the economic downturn started in 2008. In a July 2013 NACCHO study, 48 percent of North Carolina’s health departments reported losing staff. About half reported making cuts to at least one program and more than a third of the state’s public health departments reported reduced funding in the prior year while anticipating further cuts.

Even as the economy has recovered, dollars have been slow to come back. Of the total state budget for the Department of Health and Human Services, only 0.13 percent goes to local public health departments. And cuts to Medicaid reimbursement in last year’s state budget trimmed that revenue further.

Wos acknowledged that Medicaid’s massive budget overshadows the needs of public health departments. And around the hallways, individual health directors said that while they feel as if Wos “gets” public health’s importance, they also said they feel like an afterthought in the state budgeting process.

“I can understand why they would feel that,” Wos said. “The focus of the General Assembly and the amount of programs and the amount of challenges and opportunities is huge. It does not mean that a smaller portfolio is not important, but it does not get the spotlight publicly.”

Lynette Tolson, executive director of the North Carolina Association of Local Health Directors, pointed out that many of public health departments’ activities are mandated by the General Assembly, but that the money often doesn’t follow.

“We do environmental health, we inspect your private wells, we go into restaurants and your food and lodging facilities, we’re the group that makes sure that these are safe place to eat and sleep,” Tolson said.

The legislature determines fees for some of that work and county dollars make up for much of what the state doesn’t fund. But county budgets have been trimmed in recent years too, according to Buck Wilson, the health director in Cumberland County and president of the NCALHD. He said county funding for public health departments covers from as little as 3 percent in some counties to as much as 70 percent.

There’s a constant need to educate county commissioners on the need and importance of maintaining public health effort, he said.

“If people are not healthy, they’re not working, they’re missing school, they’re not generating revenue, it all goes together,” said Wilson, who added that commissioners often don’t see the return on investment from public health funding until health directors spell it out for them.

Tolson said funding doesn’t often cover routine costs or the extra dollars needed for incidents such as disease outbreaks.

Ebola response stretches staff thin

Orange County health director Colleen Bridges said her department has spent at least an additional $40,000 to pay staff for monitoring people returning from countries where Ebola virus is epidemic. She explained that to monitor for Ebola, nurses go out to people’s homes in order to see them face to face and watch as they take a temperature reading.

State epidemiologist Megan Davies said people in her office have been putting in a lot of overtime to keep tabs on Ebola since the summer, and they’re getting tired. And she said it’s not like you can quickly find a highly skilled epidemiologist to fill the gap. Congress finally appropriated money to cover some of the costs of monitoring, but Davies said that money hasn’t yet trickled down to states.

“We make sure that the diseases such as Ebola are not spread,” Tolson said. “We’re all excited that we’ve only had two deaths in this country because of Ebola, but we forget that it’s public health behind the scenes quietly doing its job.”

Wos said this year’s public health victories – successfully handling Ebola and a challenging flu season – is an opportunity to showcase public health at the legislature. And she said that could be an advantage when making funding requests to legislators for the coming year.

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