Some crusty old Health Officer once said, “When you’ve seen one local health department, you’ve seen one local health department.” Indeed, local health departments (LHD) in Maryland come in many shapes and sizes. They represent a complex web of programs to assist with the delivery and coordination of public health services. These services may range from maternal health and drug abuse treatment, to the inspection of food facilities and environmental testing.
A publication from the National Association of County and City Health Officials describes a local health department as follows:
America’s local health departments keep people healthy. They protect the water we drink, the food we eat, and the air we breathe. They detect and stop outbreaks of disease like measles and tuberculosis. They also lead efforts that prevent and reduce the effects of chronic diseases such as diabetes, asthma, and cancer.
Local health departments help create and maintain conditions in communities that make it easier for people to make healthier individual choices. They provide basic public health services that people count on and protect and improve health in ways that health insurance companies or medical care providers cannot.
This blog post is the second in a series on LHDs and will examine their services provided, structure and staffing, and funding.
In Maryland, local health services, otherwise known as “core local health services,” are broadly divided into categories as specified by State law. Funding provided by the State through the Core Funding Formula is allocated across these categories based upon priorities determined by the LHD.
- Communicable Disease Control – includes programs to prevent and control the spread of the Human Immunodeficiency Virus as well as other sexually transmitted diseases, tuberculosis-control programs, and childhood vaccination programs
- Environmental Health – works in conjunction with the Maryland Department of the Environment to increase awareness of environmental hazards, examples include development review, septic system and well permits
- Family Planning – provides planning and reproductive health services, including pregnancy prevention and female reproductive health screening
- Maternal and Child Health – provides case management for medically vulnerable children, administers pre-school vaccination programs, and provides school-based programming in conjunction with the Maryland State Department of Education, as well as abstinence education and lead poisoning prevention and control
- Wellness Promotion – Promotes healthy lifestyles and physical activity
- Adult and Geriatric Health – coordinates programs to reduce death and disability due to chronic disease
- Administration – provides for budgeting and personnel functions as well as health planning, data collection, and coalition building
Most health departments offer these services. However, LHDs also receive Federal and State grant funding, which may include funds for substance abuse treatment, child and maternal health programs, school health services, health services for the elderly, and mental health programs. LHD’s may also offer smoking cessation programs, assist with determining eligibility for the Maryland Children’s Health Insurance Program, and offer assistance to the uninsured to help them gain access to health care. Some health departments may offer all of these programs and services, others may offer a select few based on community need, while others may contract with non-profits or other outside entities.
With respect to mental health services, each local jurisdiction has a core services agency which is responsible for planning, coordinating, and monitoring publicly funded mental health services. Ten LHDs serve as core service agencies for their jurisdictions and receive grants for administration and services. The other jurisdictions contract with private, nonprofits to fill this role.
Some would argue that this widely varied role makes LHDs difficult to understand, which ultimately leads to their underfunding.
STRUCTURE AND STAFFING
Each county is required by statute to establish a local board of health, which can institute limited health rules and regulations upon compliance with the requirements set out in State law. The county governing body fulfills this role, unless in a code or charter county, the governing body chooses to establish a separate board.
In addition, each county has a local health officer who is nominated by each county governing body and appointed by the Secretary of the Department of Health and Mental Hygiene. A health officer does not need to be a physician if his or her deputy health is a physician. Currently, one-half of the State’s 22 health officers are non-physicians. (Two health officers are assigned two counties each, Charles and Queen Anne’s, and Kent and Caroline.)
The local health officer serves as the executive director of the health department and is responsible for appointing staff and enforcing the health laws and policies adopted by the State and local jurisdiction. While all health officers are State employees, LHD employees may be State or county employees based on the preference of the home rule jurisdiction. Health department employees in Baltimore City and Baltimore, Montgomery, and Prince George’s counties are county employees, whereas employees in all other counties are State employees. A substantial number of LHD State employees are funded with county money. This mixture of State/county funding for these employees can result in problems with tabulating whose employees they are. Many times these employees are excluded from total employee counts at the State and county level, which can create problems when salary or other compensation related adjustments are made.
Staffing levels range from department heads which manage various functional units, to mid-level supervisors, to administrative staff. As expected, the number of staff varies by the size of the jurisdiction. Very small LHDs, such as Caroline County, employ approximately 110 employees, while those that are larger, such as Baltimore County, employ 528.
LHDs are funded through a combination of federal, State, and county funds as well as fees. A previous blog provided a broad general overview of funding and recent reductions in State aid. This piece will provide more detail on overall funding by source.
Traditional public health services, such as the core local health services mentioned above, are funded through the Core Funding Formula. Core Funding is State/county matching funding formula set out in State law and regulation. The formula contains $4.5 million in federal funds. Counties have the ability to add additional county funds over and above their required match if they choose to do so.
The minimum State funding level was set at $41.0 million in FY 1997, with subsequent increases based on inflation and population growth. These inflationary factors increased funding to a high of almost $70 million in State General funds in FY 2008. However, cost containment actions by the Board of Public Works in August 2010 and further action during the 2010 General Assembly session, reduced the base State funding level to $37.3 million for FY 2010 to FY 2012. Inflationary increases will begin again in FY 2013, but instead of providing for cumulative growth, due to a new interpretation of the statute, the inflationary increases would only be applied as one year’s growth, permanently reducing and restructuring LHD funding. A subsequent blog will provide the history of the Core Funding Formula, more on the new statutory interpretation, and the effects on LHD.
LHDs also receive Federal and State funding to provide a number of specific services through grant agreements with the Department of Health and Mental Hygiene. This may represent 50% or more of a LHDs budget. The types of services provided may include substance abuse treatment, child and maternal health programs, school health services, health services for the aged, and mental health programs.
Although minimal, LHDs do collect fees for some of the services provided. Fees may be for restaurant inspections, environmental testing, or clinic services. If for clinic services, fees are set on a sliding scale, based on income and family size. In most cases, fees collected do not cover the cost of providing the services.
The link below provides a summary of the State, local, and federal funding for each county by source. In FY 2009, the last year these figures were compiled and the year before cost containment, LHDs received a total of $440 million, of which 55% was through grant agreements with DHMH, 14% through the Core Funding formula, and 31% through local funding. Since that time, Core Funding has been reduced by over 40%; federal programs, such as funding for H1N1, have been eliminated; and, local governments have reduced funding to accommodate State aid reductions, maintain education funding as required by law, and other lost revenues.
The following link provides a breakdown of expenditures by county, the county’s required match, and how much counties are funding over the required match. In FY 2009, county expenditures totaled $135.8 million and counties overfunded the match by $81.7 million.
Part three of this series will provide a history of the Core Funding Formula.
Previous blogs in the series are listed below.