Amended in Assembly April 6, 2016

California Legislature—2015–16 Regular Session

Assembly BillNo. 2424

Introduced by Assembly Member Gomez

February 19, 2016

An act to add Part 8 (commencing with Sectionbegin delete 106100)end deletebegin insert 106050)end insert to Division 103 of the Health and Safety Code, relating to public health.


AB 2424, as amended, Gomez. begin deleteHealth end deletebegin insertCommunity-based Health end insertImprovement and Innovation Fund.

Existing law establishes the State Department of Public Health, within the California Health and Human Services Agency, vested with certain duties, powers, functions, jurisdiction, and responsibilities over specified public health programs.

Thisbegin delete billend deletebegin insert bill, among other things,end insert would create thebegin insert Community-basedend insert Health Improvement and Innovation Fund in the State Treasury and the moneys in the fund would be available, upon appropriation by the Legislature, for certain purposes, including, but not limited to, reducingbegin delete the rates of preventable health conditions and addressing health disparities.end deletebegin insert health inequity and disparities in the rates and outcomes of priority chronic health conditions, as defined, preventing the onset of priority chronic health conditions using community-based strategies in communities statewide and with particular focus on health equity priority populations, as defined, and strengthening local and regional collaborations between local public health jurisdictions and health care providers, and across government agencies and community partners to create healthier communities, using a health in all policies approach.end insert The department would be requiredbegin insert to use a specified percentage of moneys from the fund for certain public health and administrative activities and would be requiredend insert to awardbegin insert a specified percentage ofend insert moneys from the fund to eligiblebegin delete applicants, as described.end deletebegin insert applicants to be used to improve health and health equity, as provided.end insert

begin insert

This bill would create an advisory committee, with the members serving terms not to exceed 4 years, and would require the advisory committee to provide expert input and offer guidance to the department on the development, implementation, and evaluation of the fund. The bill would require the advisory committee to produce, and periodically revise, a comprehensive master plan for advancing chronic disease and injury prevention throughout the state and would require the advisory committee to submit the master plan and its revisions to the Legislature triennially.

end insert

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.

The people of the State of California do enact as follows:

P2    1begin insert

begin insertSECTION 1.end insert  

end insert

begin insertPart 8 (commencing with Section 106050) is
2added to Division 103 of the end insert
begin insertHealth and Safety Codeend insertbegin insert, to read:end insert

begin insert


4PART begin insert8.end insert  Community-based Health Improvement and
5Innovation Fund




begin insert106050.end insert  

The Legislature finds and declares all of the following:

(a) Over the past century, chronic diseases have emerged as a
9predominant challenge to public health. Chronic disease and injury
10account for eight of every 10 deaths and affects the quality of life
11of 14 million Californians.

(b) Obesity and diabetes in particular have grown rapidly,
13posing a grave threat to health. Today over one-half of California
14adults are estimated to have either diabetes or prediabetes.
15Thirteen million adults in California, 46 percent of the adult
16population, are estimated to have prediabetes or undiagnosed
17diabetes, while another 2.5 million adults, 9 percent of the adult
18population, have already been diagnosed with diabetes.

(c) The health inequities in this state are stark:

(1) Ethnic minorities and individuals who have low incomes
21have higher rates of diabetes. Nearly one-in-five African-Americans
P3    1and Latinos in California have diabetes, more than double the
2rate of Whites.

(2) Nearly 12 years of life separate the life expectancy at the
4top and at the bottom of neighborhood clusters in California, from
5a life expectancy of 87 years in parts of northwest Santa Clara
6County to 75.3 years in the City of Twenty-Nine Palms and the
7City of Barstow in the County of San Bernardino.

(3) Economically disadvantaged children are far less likely to
9complete the fitness requirements of the physical fitness test offered
10to students in grade school.

(4) Adolescents covered by Medi-Cal reported significantly
12higher rates of drinking sugar-sweetened beverages and less daily
13consumption of vegetables than the general California adolescent
14population and were significantly more likely to be obese.

(d) The following short list of risk factors is responsible for
16much of the burden of chronic disease: tobacco use, physical
17inactivity, unhealthful diet, excessive consumption of alcohol,
18hyperlipidemia, and uncontrolled high blood pressure. These risk
19factors and chronic conditions are largely preventable and
20inequitably distributed.

(e) The State Department of Public Health estimates that as
22much as 80 percent of heart disease, stroke, and type II diabetes
23and more than 30 percent of cancers can be prevented by
24eliminating the underlying risk factors.

(f) The economic burden of chronic disease in California weighs
26heavily on families, employers, and all levels of government.
27Approximately $98 billion, or 42 percent of all health care
28expenditures in the state, was spent on treating just six common
29chronic health conditions (arthritis, asthma, cardiovascular
30disease, diabetes, cancer, and depression) in 2010.

(g) The indirect costs associated with chronic disease in
32California are also high. According to the Economic Burden of
33Chronic Disease (EBCD) Index, the projected impact of lower
34productivity and lost workdays for individuals with chronic
35conditions and their caregiving family members in California was
36estimated to be $51 billion in 2010.

(h) The cost of health care continues to surpass the rate of
38inflation, causing increasing strain on the budgets of families,
39 employers, and the government.

P4    1
(i) Despite the fact that chronic disease results in decreased
2quality of life, premature death, and exorbitant medical costs,
3investments in measures that prevent chronic disease have been

(j) The United States spends only 2.6 percent of health care
6dollars on all public health, yet 75 percent of health care costs
7are attributable to preventable health conditions.

(k) Paying for prevention works and upstream strategies have
9a remarkable history of success, measured in both cost avoidance
10and health improvement. In the County of Los Angeles, smoking
11amongst high school students fell from 27 percent to 7 percent
12between 1997 and 2013, thanks to investment in policy and
13environmental changes as well as education.

(l) Childhood obesity amongst Los Angeles Unified School
15District 5th graders decreased by 10.6 percent (from 31.2 percent
16to 27.9 percent) between 2010 and 2013, and leveled off among
177th and 9th graders, after nine years of steady increases, reflecting
18investments to reduce the consumption of sugar sweetened
19beverages, promote healthier eating, and increase physical activity.

(m) The California Health and Human Services Agency, in
21partnership with the State Department of Public Health, has
22defined ambitious health improvement goals for the state through
23the “Let’s Get Healthy California” initiative, including making
24California the healthiest state in the nation by 2022, reducing
25health disparities, and achieving better health at lower cost. These
26goals cannot be met by improvements in health care or on an
27individual basis alone. Meeting these goals requires urgent and
28substantial investment in community-based prevention of chronic

(n) The existing limited resources of funding for chronic disease
31prevention are threatened, declining from past levels, and subject
32to significant restrictions.

(o) Strategic investment in upstream prevention will protect,
34not deplete, the coffers of government. Investment in prevention
35has a strong evidence base of positive return on investment through
36reducing health care costs on a long-term basis.


begin insert106051.end insert  

For purposes of this part, the following terms have
38the following definitions:

(a) “Department” means the State Department of Public Health.

P5    1
(b) “Fund” means the Community-based Health Improvement
2and Innovation Fund.

(c) “Health equity priority population” means, for each
4condition, populations that exhibit significant disparities with
5respect to prevalence of a priority chronic health condition or
6injury or worse outcomes such as higher hospitalization or death
7rates. Priority populations may be defined based on race, ethnicity,
8geography, socioeconomic status including income or education,
9other factors as defined by the department, or current findings and
10recommendations of research, including assessments of innovations
11funded by the fund.

(d)  “Local health jurisdiction” means county health department
13or combined health department in the case of counties acting jointly
14or city health department within the meaning of Section 101185.

(e) “Priority chronic health conditions” means asthma, type II
16diabetes, cardiovascular and cerebrovascular disease, cancer,
17dental disease, obesity, and other chronic conditions and injuries
18that are prevalent, largely preventable, and associated with high
19health care costs, as defined by the department. High-burden
20conditions whose prevention is not adequately supported by other
21funding streams shall be prioritized.


begin insert106052.end insert  

(a) (1) There is hereby created in the State Treasury
23the Community-based Health Improvement and Innovation Fund.
24The fund shall consist of any revenues deposited therein, including
25any fine or penalty revenue allocated to the fund, any revenue from
26appropriations specifically designated to be credited to the fund,
27any funds from public or private gifts, grants, or donations, any
28interest earned on that revenue, and any funds provided from any
29other source.

(2) A target level of annual statewide investment from the fund
31shall be established as a set dollar amount per capita, to be
32allocated for the purposes described in subdivision (b) and as
33described in subdivision (c).

(b) (1) Moneys in the fund shall be available, upon
35appropriation by the Legislature, for any of the following purposes:

(A) Reducing health inequity and disparities in the rates and
37outcomes of priority chronic health conditions.

(B) Preventing the onset of priority chronic health conditions
39using community-based strategies in communities statewide and
40with particular focus on health equity priority populations.

P6    1
(C) Strengthening local and regional collaborations between
2local public health jurisdictions and health care providers, and
3across government agencies and community partners to create
4healthier communities, using a health in all policies approach.

(D) Contributing to a stronger evidence base of effective
6community-based prevention strategies for priority chronic health

(E) Evaluating effectiveness and cost-effectiveness of innovative
9community-based prevention strategies for priority chronic health
10conditions, as a basis for future decisions about investment in
11those strategies in order to reduce the costs of providing health
12care services and to improve population health status.

(2) Moneys in the fund shall be used to address social,
14environmental, and behavioral determinants of chronic disease
15and injury at any phase of the life cycle, including, but not limited
16to, all of the following:

(A) Promotion of healthy diets and food environments.

(B) Promotion of physical activity and of a safe, physical
19 activity-promoting environment.

(C) Prevention of unintentional and intentional injury.

(3) In expending moneys from the fund, policy, systems, and
22environmental change approaches are to be emphasized, although
23funds can support implementation of community-based programs.

(4) Moneys in the fund shall not be used for clinical services.

(c) Revenues deposited in the fund that are unexpended at the
26end of a fiscal year shall remain in the fund and not revert to the
27General Fund.


begin insert106053.end insert  

(a) The department shall be allocated an amount not
29greater than 20 percent of the annual appropriation from the fund
30for all of the following activities:

(1) Mandatory activities for which the funds shall be used are
32as follows:

(A) Statewide media and communications campaigns, which
34shall be allocated 9 percent of those funds.

(B) Evaluation of program activities, which shall be allocated
36at least 5 percent of those funds.

(C) Other activities, which shall be allocated no more than 6
38percent of those funds, as follows:

(i) Mandatory activities, including all of the following:

(I) Overall program implementation and oversight.

P7    1
(II) Review and approval of local health improvement plans.

(III) Granting of and monitoring the implementation of local
3health jurisdiction awards and competitive grant awards.

(ii) The definition of criteria for evidence-based and innovative
5approaches to improving health and health equity, with evaluation
6criteria appropriate to each type of approach.

(iii) The definition of priority chronic health conditions and
8health equity priority populations based on public health data.

(iv) The definition of criteria for participation of community
10partners in local health jurisdiction funding.

(v) The development of tools that can be used by the state and
12by grantees to monitor progress towards improving health and
13health equity, including establishment of a health equity index.

(2) Discretionary activities, as may be appropriate to support
15community-based prevention of priority chronic health conditions
16throughout the state, for which the funds may be used, include,
17but are not limited to, any of the following:

(A) Research, development, and dissemination of best practices,
19including training and technical assistance for grantees.

(B) Development of infrastructure, including, but not limited
21to, data resources or information technology resources to be shared

(C) Coordination of local efforts.

(D) Development and promotion of statewide initiatives.

(b) The department shall award at least 80 percent of total
26moneys made available in the annual appropriation from the fund
27to eligible applicants to be used consistent with the purposes
28described in subdivision (b) of Section 106052. Moneys from the
29fund shall be distributed and awarded according to the following

(1) (A) At least 50 percent of those funds shall be awarded to
32local health jurisdictions and shall be allocated on a formula basis
33to local health jurisdictions, or their nonprofit designee, with
34approved applications for three-year funding cycles.

(B) Each local health jurisdiction shall submit an application
36for a three-year funding cycle, to be reviewed and approved by
37the department, that includes all of the following information:

(i) A detailed assessment of community health needs within the
39local health jurisdiction with respect to priority chronic health
40conditions and health equity priority populations.

P8    1
(ii) A health improvement and evaluation plan that includes
2initiatives focused on health equity priority populations.

(iii) The level of local funds, including in-kind resources, for
4community-based prevention activities that was provided in the
5most recently completed fiscal year.

(iv) Documentation of the existence and activities of a
7community health partnership, which includes leading health care
8providers, local health jurisdictions, community partners, including
9those serving health equity priority populations, businesses, and
10other relevant local government agencies and community leaders.

(C) Each local health jurisdiction with an approved application
12shall receive a base award of two hundred fifty thousand dollars
13($250,000) for a three-year funding cycle. The balance of the funds
14shall be awarded to local health jurisdictions proportional to the
15number of residents living below the federal poverty level.

(D) Health improvement and evaluation plans shall emphasize
17sustainable policy, systems, and environmental change approaches
18to creating healthier communities.

(E) Local health jurisdictions may come together if they so
20desire to submit combined regional applications.

(F) No single recipient may receive more than 30 percent of the
22funding allocated to local health jurisdictions on a formula basis.

(G) Recipients of funds pursuant to this paragraph shall
24maintain the level of local funds, including in-kind resources, for
25community-based prevention activities that were provided in the
26most recent completed fiscal year prior to July 2016. Funds
27provided pursuant to this paragraph shall supplement and not
28supplant existing funding for community-based prevention activities
29of priority chronic health conditions.

(H) Local health jurisdiction investments shall prioritize
31communities in the third and fourth quartiles of the California
32Health Disadvantage Index or other criteria of health equity
33priority populations subsequently adopted by the department.

(I) The initial year of funding may be used for needs assessment,
35planning, and development.

(2) At least 30 percent of those funds shall be allocated for
37competitive grants as follows:

(A) (i) Competitive grants shall be awarded to local or regional
39level entities or statewide nonprofit organizations.

P9    1
(ii) Local or regional level entities include community-based
2organizations or local public agencies, in partnership with other
3entities, including, but not limited to, other community-based
4organizations, other local public agencies, schools, religious
5organizations, businesses, labor unions, health care plans,
6hospitals, clinics, other health care providers, or other
7community-based entities.

(iii) Each participating health care plan or hospital shall identify
9monetary, in-kind, or both, contributions to projects.

(iv) Local or regional projects shall prioritize investments that
11serve communities in the third and fourth quartiles of the California
12Health Disadvantage Index or other criteria of health equity
13priority populations subsequently adopted by the department.

(v) At least 10 percent of the funds awarded as competitive
15grants shall be used for statewide nonprofit organizations.

(vi) Organizations receiving competitive grants shall coordinate
17efforts with any local health jurisdictions where they are carrying
18out activities.

(B) (i) Competitive grant applicants shall identify projects as
20either an evidence-based or an innovative project.

(ii) At least 10 percent of the funding for competitive grants
22shall be set aside for innovative projects that test previously
23untested strategies in order to improve the evidence base of
24effective community-based prevention strategies for priority
25chronic health conditions.

(iii) Applications for innovative projects shall provide a
27rationale for the defined approach and any evidence that suggests
28the innovative project will be effective, as well as a plan and
29resource allocation for the evaluation.

(iv) Competitive grants may be used by organizations for policy
31systems or environmental change efforts, direct program delivery,
32or for technical assistance to other grantees.


begin insert106054.end insert  

(a) (1) An advisory committee, with the members
34serving terms not to exceed four years, shall provide expert input
35and offer guidance to the department on the development,
36implementation, and evaluation of the fund.

(2) The advisory committee shall include, at a minimum, experts
38on priority chronic health conditions, effective nonclinical
39prevention strategies, policy strategies for chronic disease
P10   1prevention, and the unique needs of health equity priority

(3) The advisory committee shall include representatives from
4the State Department of Health Care Services, the Health in All
5Policies Task Force, the California Health and Human Services
6 Agency, the California Conference of Local Health Officers, and
7the California Public Employees’ Retirement System.

(b) The department shall develop a robust evaluation framework
9for all activities funded through the fund.

(c) The department may define state priorities and require
11activities funded by the fund to align with those priorities in a
12manner that is consistent with the intent of this part. The
13department may narrow the list of priority chronic health
14conditions if necessary to ensure an effective program.

(d) (1) Based on the results of programs supported by this part
16and any other proven methodologies available to the advisory
17committee, the advisory committee shall produce a comprehensive
18master plan for advancing chronic disease and injury prevention
19throughout the state.

(2) The master plan shall include recommended implementation
21strategies for each priority chronic health condition throughout
22the state and identify areas where innovative solutions are
23especially needed.

(3) The advisory committee shall submit the master plan, and
25revisions to the master plan, to the Legislature triennially.

(4) The master plan and its revisions shall include
27recommendations on specific goals for reduction of the burden of
28preventable chronic conditions and injuries by 2030, administrative
29arrangements, funding priorities, integration and coordination of
30approaches by the department, the University of California, the
31Health in All Policies Task Force, and their support systems, and
32progress reports relating to each health equity priority population.

(5) A report submitted pursuant to paragraph (3) shall be
34submitted in compliance with Section 9795 of the Government

end insert
begin delete36


Part 8 (commencing with Section 106100) is
37added to Division 103 of the Health and Safety Code, to read:


P11   1PART 8.  Health Improvement and Innovation





(a) There is hereby created in the State Treasury the
5Health Improvement and Innovation Fund.

6(b) Moneys in the fund shall be available, upon appropriation
7by the Legislature, for the following purposes:

8(1) Reduce the rates of preventable health conditions.

9(2) Address health disparities.

10(3) Reduce state health care costs.

11(4) Build evidence of effective prevention programs.

12(c) (1) The State Department of Public Health shall award
13moneys from the fund to eligible applicants.

14(2) Eligible applicants shall include, but not be limited to,
15community-based organizations and local governments.

end delete