BILL ANALYSIS ---------------------------------------------------------- |Hearing Date:January 11, 2006 |Bill No:SB | | |162 | ---------------------------------------------------------- SENATE COMMITTEE ON GOVERNMENT MODERNIZATION, EFFICIENCY, AND ACCOUNTABILITY Senator Liz Figueroa, Chair Bill No: SB 162 Author: Senator Ortiz As Amended: March 30, 2005 Fiscal:Yes SUBJECT: State Department of Public Health. SUMMARY: Establishes a Department of Public Health (DPH) within the Health and Human Services Agency, and transfers various responsibilities relating to public health, currently administered by the Department of Health Services (DHS), to the new department. Establishes a 13-member Public Health Board to provide public and expert involvement in the development of policies, regulations, and programs administered by the DPH or directly affecting the health of Californians. Requires this bill to be implemented on January 1, 2007, but only if an appropriation for the purposes of this bill is made in the Budget Act of 2006. Existing law: Establishes the DHS within the Health and Human Services Agency and gives the DHS responsibility over a variety of health-related programs, including public health, Medi-Cal and other public aid health care programs. This bill: 1)Establishes the DPH within the Health and Human Services Agency, under the control of a State Health Officer who is a licensed physician appointed by the Governor and confirmed by the Senate. 2)Provides that the DPH succeeds to, and is vested with, the duties, purposes, responsibilities, and jurisdiction exercised by the DHS, as specified, with respect to all the following provisions of law: SB 162 Page 2 a) The Office of Binational Border Health; b) The Public Health Federal Fund, and the state laboratory in Richmond; c) Regulation of laboratories; d) Provisions of law relating to local health officers; e) Vital Records and Health Statistics; f) Disease Prevention and Health Promotion; g) Environmental Health; h) Communicable Disease Prevention and Control; and, i) Maternal, Child and Adolescent Health Care. 3)States the intent of the Legislature that the jurisdiction of the DPH also includes other programs that are related to public health. 4)Transfers the Division of Rural Health from the DHS to the DPH. 5)Transfers the Office of AIDS from the DHS to the DPH. 6)Transfers the authority to commence all proper and necessary actions for the following purposes from the DHS to the DPH: to conjoin and abate nuisances dangerous to health; to compel the performance of any act specifically enjoined upon any person, officer, or board, by any law of this state relating to public health; and, to protect and preserve the public health. 7)Transfers the authority to perform certain activities to protect, preserve and advance the public health from the DHS to the DPH, including studies, demonstrations of innovative methods, provision of training programs, and dissemination of information. 8)Requires the DPH to have the same rulemaking authority vested in the DHS with respect to those programs transferred from that department. Requires all regulations heretofore adopted by the DHS relating to public health or any other function performed by the DHS to remain in effect and be fully enforceable unless and until readopted, amended, or repealed by the State Health Officer. 9)Transfers from the DHS to the DPH the requirement to maintain a laboratory and branch laboratories as may be necessary to perform the microbiological, physical, and chemical analyses required to meet the responsibilities of the DPH. SB 162 Page 3 10)States the intent of the Legislature that all public health programs currently operated through the DHS to be transferred to the DPH, without regard to whether or not that public health program has been formally created by statute, and defines "public health program," for purposes of this intent language, as referring primarily to programs and functions that seek to prevent illness and promote health, as compared to programs involving either the direct delivery of health care services or the payment for those services. 11)Establishes the Public Health Board (Board) to provide public and expert involvement in the development of policies, regulations, and programs administered by the DPH or directly affecting the health of Californians. 12)Requires the Board to consist of 13 voting members, as follows: a) A dean of a California school of public health, appointed by the Governor; b) A dean of a California school of nursing, appointed by the Governor; c) A dean of a California school of medicine, appointed by the Governor; d) A public laboratory director, appointed by the Governor; e) Two public members of national stature with broad experience and professional expertise in public health, one each appointed by the Speaker of the Assembly and the Senate Committee on Rules; f) Two members from community-based organizations with an interest and mission of promoting public health, one each appointed by the Speaker of the Assembly and the Senate Committee on Rules; g) The State Health Officer (who is required to be the chairperson); h) The physician leader of the state's medical emergency response system; i) The President of the California Conference of Local Health Officers; j) The health officer of a large metropolis, appointed by the President of the California Conference of Local Health Officers; and, aa) A rural health officer, appointed by the President of the California Conference of Local Health Officers. SB 162 Page 4 13)Requires members of the Board to serve on a voluntary basis and not receive any compensation for the performance of their duties. 14)Requires the Board to be provided independent professional staff through the reassignment of existing resources. 15)Requires the Board to do all of the following: a) Through public meetings, provide oversight of public health programs and regulations to improve effectiveness, examine ways to better use existing resources, analyze cost-effective alternatives for improving the health and safety of Californians, and comment on regulations that will affect the public health; b) Encourage the participation of related government agencies, such as the health professions boards and the National Guard, as well as foundations and professional associations, including the County Health Executives Association, the Public Hospital Association, the California Medical Association, the California Health Care Association, the Western Occupational and Environmental Medical Association, the California Conference of Local Health Department Nursing Directors, and the public health associations; c) Systematically assess the opportunities to consolidate or coordinate the work of other state health-related advisory boards, such as the Health Policy and Data Advisory Committee of the Office of Statewide Health Planning and Development; d) Encourage the development of effective partnerships to tap the expertise of California's universities, academic medical centers, community clinics, foundations, private medicine, and the National Guard; e) Explore strategic relationships with biotechnology and other high technology sectors; and, f) Report at least annually to the Governor and Legislature on the priorities for government actions to improve the public health and on ways resources could be used more effectively. 16)Requires the DHS, or the DPH if it has been established pursuant to this bill, to convene a workgroup of experts to develop specific recommendations on the creation of the DPH and how the DPH fits into a long-term strategy to improve the future of public health leadership in California. Requires SB 162 Page 5 the workgroup to provide its recommendations and strategy to the Governor and Legislature six months after the convening of the workgroup. Specifies that this provisions shall only be implemented upon the receipt by the DHS of sufficient nonstate resources to cover all costs, including the costs of staff resources and of implementing this section. Specifies that the establishment of the DPH is not contingent upon the formation or recommendations of this workgroup. 17)Specifies that this bill, with the exception of the working group described above, becomes operative on January 1, 2007, and only if an appropriation for the purposes of this bill is made in the Budget Act of 2006. FISCAL EFFECT: Unknown. COMMENTS: 1)Purpose. According to the author, public health programs and goals are constantly overlooked and overshadowed by the Medi-Cal program. Furthermore, several independent studies have concluded that California suffers from a severe lack of strong and effective state public health leadership. A new department would create the opportunity to build strong leadership, resulting in increased protection of the public health and safety for Californians. California's local public health officers are among the first responders to any public health threat, and are the first to identify unusual disease occurrences. These officials must not only respond to threats of bioterrorism, but must continue to control the spread of diseases such as meningitis, HIV, hepatitis C, and Chlamydia, among others. Counties rely on local public health agencies to detect and respond effectively to significant threats, including major outbreaks of infectious disease, pathogens resistant to antimicrobial agents, and acts of bioterrorism. 2)Senate Public Health Hearing. On June 2, 2004, the Senate Health and Human Services Committee held a hearing titled "Public Health: Will California Rise to the Challenge?" Representatives from a variety of organizations, including RAND, the Little Hoover Commission, the California Medical Association, the California Conference of Local Health SB 162 Page 6 Officers, and the County Health Executives Association of California testified before the Committee regarding the nature of work undertaken by DHS, the role of public health at that state and local levels, and the need for a separate State DPH. Studies on the subject by the Little Hoover Commission and RAND were reviewed and a Legislative Analyst Office analysis of the Little Hoover Commission report was shared with members of the Committee. 3)Little Hoover Commission Reports. In April 2003, the Little Hoover Commission released a report that found that California's public health leadership and organizational structure is ill-prepared to fulfill the primary obligation of reducing injury and death from threats to public health such as environmental hazards, bioterrorism and emerging infectious diseases. The report recommended that a public health department, separate from Medi-Cal and other public health insurance programs, be created to focus on emerging threats, with physician and science-based leadership and an advisory board that links California's health assets and experts. The report went on to name core public health functions that the new department should undertake, including laboratory, surveillance, and prevention services; emergency services; food, drug, and drinking water safety; and functions of the Office of Statewide Health Planning and Development (OSHPD). The Little Hoover Commission conducted their study because of concerns about the ability of California's public health system to respond to a large-scale public health emergency, especially in light of the elevated concerns as the United States faces potential threats of bioterrorism. With the events following September 11, 2001, many are concerned that possible terror attacks may include unconventional weapons, such as biological pathogens. In June of 2005, the Little Hoover Commission followed up on its April 2003 report and other recommendations it has made in the past few years regarding the preparedness of California to respond to emergencies. The Commission stated that it found that several of its prior recommendations for improvements have not been made a priority, and urged the Governor and the Legislature to prioritize certain recommendations, including enacting legislation to establish the separate department of public health, with physician leadership and with advice and oversight of a scientific public health board. SB 162 Page 7 4)RAND Study. In June 2004, the RAND Center for Domestic and International Health Security released a report that examined California's public health preparedness as a result of a request for this information by the Little Hoover Commission. To complete their assessment, they reviewed the federal Centers for Disease Control and Prevention (CDC) Local Preparedness Capacity Inventories from 2002 and conducted a series of site visits to determine preparedness for a public health emergency. Among their findings were: a) There is widespread variation among local health jurisdictions with respect to ability to respond to infectious disease outbreaks and other public health threats; b) There is considerable ambiguity surrounding the appropriate roles for a local health jurisdiction, other local agencies and the DHS; c) There appears to be lacking a strong, central leadership and coordination of public health; and, d) The current organization of public health preparedness activities in California leads to redundancies and inefficiencies. Based on those findings, RAND made a number of recommendations, including that the organization of public health in California be examined and that the role of strong, central leadership focused on public health at a state level is a key component to that reexamination. The study also called for improvement in the statewide epidemiologic information system and the maintenance of a highly skilled public health workforce in California, including workforce planning activities. Finally, the report called for an evaluation of public health preparedness at the state level to more fully understand the preparedness issues identified in the report. According to RAND, such an analysis would be considered background work required prior to reorganization of public health in California. In cases involving major disease outbreaks, city, county, and state health departments act as the nation's first line of defense, supported by the CDC, the National Institutes of Health, and other federal agencies. Local health departments serve as the backbone for detection and response to a biological weapons attack, supporting local law enforcement, fire departments, and HAZMAT teams in identifying the bacteria, and controlling its spread. SB 162 Page 8 1)LAO Analysis. In early 2004, the author of this bill requested that the LAO analyze the Little Hoover Commission report. The LAO analysis outlined the advantages and disadvantages of creating a DPH. According to the report, DHS is projected to dedicate over 48% of its staff and 96% of its total resources to health service delivery (for Medi-Cal and other health care programs) in 2003-04. Therefore, the distribution of resources may have effect on the focus of the DHS and its leadership on the Medi-Cal program. According to the LAO, the main advantage of centralizing public health activities is a greater focus on improving health through public health activities. Additionally, to the extent that reductions or slower growth in public health activities are a reflection of DHS priorities, it is possible that a separation from Medi-Cal would put public health budgets in a stronger position to compete for resources. A centralization of public health programs may also expedite policy and budget decisions and increase overall department responsiveness to constituency groups. Finally, a centralization of core public health functions in one department may reveal funding opportunities that are not currently apparent or accessible. The LAO analysis also outlined perceived disadvantages to the creation of a new DPH. As proposed by the Little Hoover Commission, the DPH would be on par with the California Health and Human Services Agency (CHHSA) and other cabinet-level agencies, with the director reporting directly to the Governor. The LAO analysis suggested that the location of the DPH outside of CHHSA would probably hinder state efforts to coordinate health-related programs and activities. Additionally, the separation of DHS public health programs from Medi-Cal could lead to missed opportunities for the integration of public health research and information gained in the field into health care delivery systems (such as Medi-Cal managed care). Also as proposed by the Little Hoover Commission, the consolidation of OSHPD and Emergency Medical Services Authority (EMSA) with a new public health department may result in a lower emphasis on the departments' current activities and lengthen the decision-making process in relation to their issues. Additionally, these departments would have to compete against other public health programs for management's time and resources. SB 162 Page 9 SB 162 does not place the DPH in the cabinet nor include OSHPD or EMSA. 2)Related Legislation. AB 2769 (Richman, 2004) would have established a DPH and a Public Health Improvement Board and specified that the DPH is responsible for the administration of all public health programs. This bill failed passage in the Assembly Health Committee. SB 858 (Ortiz, principal coauthor Richman, 2004) was virtually identical to this bill. SB 858 was held in the Assembly Appropriations Committee. 3)Arguments in Support. The Health Officers of California (HOAC), the sponsor of SB 162, argues that DHS has as its main concern the multi-billion dollar Medi-Cal program, the size of which overshadows public health. As a result, they believe that public health preparedness and leadership have been in decline since the formation of DHS in the 1970s. The Little Hoover Commission states in support that shortly after the terrorist attacks of September 11, 2001, the Commission identified the public health system as the weakest link in California's homeland defense. The Commission concluded, based on a subsequent review of the public health infrastructure, that strengthening the public health system would require changes in organizational structure, and recommended that a new Department of Public Health be created to consolidate public health functions. The California Medical Association also support this bill, arguing that a separate Department of Public Health would help create a more coordinated, multidisciplinary approach to addressing public health threats, and would strengthen the capabilities at the stat and local levels to respond to emerging public health problems. The California Association of Professional Scientists (CAPS) states that it is concerned that public health can get lost in the shuffle because it is combined in DHS with a variety of human services functions. CAPS argues that organizing the office to provide more emphasis on public health will serve all Californians better, SB 162 Page 10 particularly given the public health threats that are looming. SUPPORT AND OPPOSITION: Support: Health Officers of California (sponsor) California Association of Professional Scientists California Medical Association Little Hoover Commission Opposition: None on file Consultant:Vincent D. Marchand