BILL ANALYSIS Ó
AB 2424
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Date of Hearing: April 19, 2016
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
AB 2424
(Gomez) - As Amended April 6, 2016
SUBJECT: Community-based Health Improvement and Innovation
Fund.
SUMMARY: Creates a Community-based Health Improvement and
Innovation (CHII) Fund for certain purposes, including funding
for health inequity and disparities in the rates and outcomes of
priority chronic health conditions. Specifically, this bill:
1)Creates in the State Treasury the CHII Fund that consists of
any revenues deposited therein, including any fine or penalty
revenue allocated to the fund, any revenue from appropriations
specifically designated to be credited to the CHII Fund, any
funds from public or private gifts, grants, or donations, any
interest earned on that revenue, and any funds provided by any
other source. States that a target level of annual statewide
investment from the fund is to be established as a set dollar
amount per capita.
2)Requires CHII Fund to be available, upon appropriation by the
Legislature, for any of the following purposes:
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a) Reducing health inequity and disparities in the rates
and outcomes of priority chronic health conditions;
b) Preventing the onset of priority chronic health
conditions using community-based strategies in communities
statewide and with particular focus on health equity
priority populations;
c) 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, as specified;
d) Contributing to a stronger evidence base of effective
community-based prevention strategies for priority chronic
health conditions; and,
e) Evaluating effectiveness and cost-effectiveness of
innovative community-based prevention strategies for
priority chronic health conditions, as specified.
3)Requires the CHII Fund to be used to address social,
environmental, and behavioral determinants of chronic disease
and injury at any phase of life cycle, including, but not
limited to all of the following:
a) Promotion of healthy diets and food environments;
b) Promotion of physical activity and of a safe, physical
activity-promoting environment; and,
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c) Prevention of unintentional and intentional injury.
4)Emphasizes policy, systems, and environmental changes
approaches, although the CHII Fund can support implementation
of community-based programs and prohibits the CHII Fund to be
used for clinical services.
5)Requires deposited revenues that are not expended at the end
of a fiscal year to remain in the CHII Fund and not revert to
the General Fund.
6)Requires the Department of Public Health (DPH) to allocate an
amount not greater than 20% of the annual appropriation from
the CHII Fund for any of the following activities:
a) Mandatory activities:
i) Statewide media and communication campaigns: 9% of
funds;
ii) Evaluation of program activities: At least 5% of
funds;
iii) Other activities: No more than 6% of those funds,
including;
(1) Mandatory activities like the overall program
implementation and oversight; review and approval of
local health improvement plans; and granting of and
monitoring the implementation of local health
jurisdictions and competitive grant awards; and,
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(2) Discretionary activities as may be appropriate
to support community-based prevention of priority
chronic health conditions, as specified, including but
not limited to any of the following:
(a) Research, development, dissemination of
best practices, as specified;
(b) Development of infrastructure, as
specified;
(c) Coordination of local efforts; and,
(d) Development and promotion of statewide
initiatives.
b) Requires DPH to award at least 80 percent of the CHII
Fund made available in the annual appropriation to eligible
applicants to be used consistent with the purposes
identified in the CHII Fund and provides for distribution
and award according to the following criteria:
i) At least 50% of those funds awarded to local health
jurisdictions and allocated on a formula basis to local
health jurisdictions, or their nonprofit designee, with
approved applications for three-year funding cycles; and,
ii) Each local health jurisdiction will submit an
application for a three-year funding cycle, reviewed and
approved by DPH, which includes all of the following:
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(1) Detailed, assessment of community health
needs, as specified;
(2) Health improvement and evaluation plan, as
specified;
(3) Level of local funds, including in-kind
resources, for community-based prevention activities,
as specified; and,
(4) Documentation of the existence and activities
of a community health partnership, as specified.
iii) Each local health jurisdiction with an approved
application shall receive a base award of $250,000 for
a three-year funding cycle. The balance of funds will
be awarded to local health jurisdictions proportional
to the number of residents living below the federal
poverty level;
iv) Health improvement and evaluation plans will
emphasize sustainable policy, systems, and
environmental change approaches to creating healthier
communities;
v) Local health jurisdictions may submit combined
regional applications;
vi) No single recipient will receive more than 30
percent of the funding allocated to local health
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jurisdictions on a formula basis;
vii) Recipients will maintain the level of local
funds, including in-kind resources, for community-based
prevention activities that were provided in the most
recent completed fiscal year prior to July 2016. CHII
Funds will supplement and not supplant existing funding
for community-based prevention activities, as
specified; and,
viii) Local health jurisdiction investments will
prioritize communities in the third and fourth
quartiles of the California Health Disadvantage Index
(CHDI) or other criteria of health equity priority
populations as subsequently adopted by DPH.
c) Requires DPH to allocate at least 30% for competitive
grants as follows:
i) To be awarded to local or regional level entities or
statewide nonprofit organizations;
ii) Local or regional level entities include
community-based organizations or local public agencies,
in partnership with other entities, as specified;
iii) Each participating health care plan or hospital will
identify monetary, in-kind, or both, contributions to
projects;
iv) Local or regional projects will prioritize
investments that serve communities in the third or fourth
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quartiles of the CHDI or other criteria, as specified;
v) At least 10% of the funds awarded will be used for
statewide nonprofit organizations; and,
vi) Organizations receiving competitive grants will
coordinate efforts with any local health jurisdictions
where they are carrying out activities.
d) Provides that competitive grants will identify projects
as either evidence-based or an innovative project.
Requires at least 10% of the funding to be set aside for
innovative projects, as specified, and applications for
innovative projects to include a rationale for the defined
approach and any evidence that suggests effectiveness, as
well as a plan and resource allocation for the evaluation.
Provides that competitive grants may be used by
organization for policy systems or environmental change
efforts, direct program delivery, or for technical
assistance to other grantees.
7)Creates an advisory committee, with members serving no more
than four years, to provide expert input and offer guidance to
DPH on the development, implementation, and evaluation of the
CHII Fund and will include, at a minimum, experts on priority
chronic health conditions, effective nonclinical prevention
strategies for chronic disease prevention, and the unique
needs of health equity priority populations. Requires
representatives from the State Department of Health Care
Services, the Health in All Policies Task Force, the
California Health and Human Services Agency, the California
Conference of Local Health Officers, and the California Public
Employees' Retirement System.
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8)Requires DPH to develop a robust evaluation framework for all
activities and states that DPH may define state priorities as
specified, and may narrow the list of priority chronic health
conditions if necessary to ensure an effective program.
9)Requires the advisory committee to produce a comprehensive
master plan for advancing chronic disease and injury
prevention through the state, based on the results of programs
and any other proven methodologies available to the advisory
committee. Provides that the master plan include
recommendations of implementation strategies, as specified;
specific goals for reduction of the burden of preventable
chronic conditions and injuries by 2030; administrative
arrangements; funding priorities; integration and coordination
of approaches by DPH, the University of California, the Health
in All Policies Task Force, and their support systems; and,
progress reports relating to each health equity priority
population. Requires the advisory committee to submit the
master plan to the Legislature triennially.
10)Defines various terms including health equity priority
population and priority chronic health conditions.
11)Finds and declares the importance of treating chronic
diseases and identifies the health inequities in this State.
EXISTING LAW establishes DPH, within the California Health and
Human Services Agency, vested with certain duties, powers,
functions, jurisdiction, and responsibilities over specified
public health programs.
FISCAL EFFECT: This bill has yet to be analyzed by a fiscal
committee.
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COMMENTS:
1)PURPOSE OF THIS BILL. The author states that with this bill
and with proper management, innovative investment strategies,
and equitable distribution and implementation plans, the CHII
Fund would help the State achieve greater health equity and
advance the "Triple Aim" of health improvement: a) better
care; b) better health; and, c) lower costs. According to the
author, a $10 per capita investment over 3 years (for
prevention of disease which accounts for 80% of health care
costs) is actually fairly modest for a statewide program with
these goals. For comparison, Massachusetts has invested a $60
million one-time in a similar fund, which is similar in scale
based on their population. The state spends over $450 per
capita from the General Fund just on Medi-Cal every year-- and
much more when accounting for California Public Employees'
Retirement System employees and retirees, as well as
correctional health.
According to the author, DPH received a grant from the Centers
for Disease Control (CDC) and Prevention for $3.8 million to
promote healthy behaviors and reduce diabetes. DPH's
Nutrition Education and Obesity Prevention Branch (NEOPB),
which addresses California's obesity epidemic by focusing on
healthy behavior changes in at-risk, low-income communities,
has major restrictions on the use of funds, and will face a
30% reduction in federal funds by 2018. Funding from
Proposition 99 for tobacco control and First 5 California has
also declined due to successful tobacco control efforts.
2)BACKGROUND. As part of the Patient Protection and Affordable
Care Act (ACA) of 2010, the Prevention and Public Health
Investment Fund (Prevention Fund) was created to provide
communities around the country with more than $15 billion over
the next 10 years to invest in effective, proven prevention
efforts, like childhood obesity and tobacco cessation. The
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Prevention Fund, in recent years, has suffered legislative
reduction and elimination of major programs.
In 2012, the Assembly and Senate Committees on Health conducted
a joint hearing with the goal of highlighting the health
benefits and cost savings associated with investing in
community-wide health promotion and disease prevention. The
hearing was also meant to highlight new developments with
federal funding for health prevention that California received
as a result of the ACA, as well as new findings about voter
options on prevention. The hearing also highlighted
prevention activities currently underway at the time across
the state to implement successful strategies aimed at reducing
health care costs and promoting health and wellness.
In 2014, the Assembly Committee on Health held an Information
Hearing, entitled Supporting Public Health in California: The
Critical Rose of the State and Local Departments in Disease
Surveillance and Control. The background included information
of the following:
a) Department of Public Health. The mission of DPH is to
optimize the health and well-being of Californians,
primarily through population-based programs, strategies,
and initiatives. DPH is broadly organized into Center for
Chronic Disease Prevention and Health Promotion (CCDP&HP),
Center for Environmental Health, Center for Family Health,
Center for Health Care Quality, and Center for Infectious
Diseases (CID). CCDP&HP is DPH's lead on climate change
and on Health in All Policies. The State of California
created the Health in All Policies Task Force in 2010. The
Task Force was charged with identifying priority programs,
policies, and strategies to improve the health of
Californians while advancing the goals of improving air and
water quality, protecting natural resources and
agricultural lands, increasing the availability of
affordable housing, improving infrastructure systems,
promoting public health, planning sustainable communities,
and meeting climate change goals. CID protects
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Californians from the threat of preventable infectious
disease and assists individuals suffering from infectious
disease by securing prompt and appropriate access to health
care, medications, and associated support services. CID
activities are a particular focus of this hearing,
specifically, the responsibility to help investigate and
diagnose infectious diseases of public health significance,
such as the flu.
b) Local Health Departments. There are 61 local health
jurisdictions in California representing the 58 counties
and three cities: Berkeley, Long Beach, and Pasadena.
Public health officers have broad far-reaching authority
and responsibility under the law. For example, public
health officers have the authority to order testing for
individuals or communities, quarantine individuals or
groups, and close beaches, restaurants, and other
facilities for public safety. Public health officers
receive reports from health providers and laboratories
concerning the incidence of more than 80 statutorily
reportable diseases including HIV/AIDs, tuberculosis, and
syphilis. County health departments must submit monthly,
quarterly, or annual public health and program reports to
state agencies including DPH and the Emergency Medical
Services Authority. County public health programs vary
substantially in their administrative structures, scope,
funding levels, staffing, and specific services and
programs offered. Counties generally provide maternal and
child health care, child health and disability prevention,
tuberculosis control, and AIDS services. Most counties
provide services related to sexually transmitted diseases,
smoking/tobacco cessation, childhood lead poisoning, and
immunizations. Many counties have also developed their own
innovative programs. For example, the City of Berkeley
Public Health Department has modeled a Healthy Restaurant
Program on the Bay Area Green Business Project, which works
with businesses to implement sustainable practices and is
working with restaurants to help them to increase healthy
menu options. The Community Health Department in Fresno
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County developed the Women's Health Education and Outreach
Program, which instituted Valley Women Care Clubs that
hosted monthly workshops for a total of eight months in a
chosen community. The workshops focused on reducing
chronic disease risk through nutrition education, food
tastings and food preparation demonstrations, physical
activity sessions, and discussion on health perceptions and
practices. Unfortunately due to a lack of funding this
program was later cut.
c) Public Health Spending in California. At the State
level, the Governor's fiscal year (FY) 2014-15 Budget
provides $3 billion for the support of DPH programs and
services, a decrease of 11.4% from the previous year. Of
the amount approved, 23% ($683.3 million) is for state
operations and 77% ($2.3 billion) is for local assistance.
There are two broad types of funding for public health in
California: categorical (consisting largely of federal
funding) and flexible (consisting of funding from public
health realignment and local sources). Each local health
department is unique in its mixture of these funds. A
consistent challenge is that flexible funds must be
prioritized to support mandated functions such as
communicable disease control, which receives little to no
categorical funding. Consequently, flexible funding
available for other public health functions - such as
chronic disease prevention - is very limited. When there
are reductions to flexible funding, there is a
disproportionate impact on mandated public health services.
Recent reductions to realignment may further reduce
funding for public health programs as they compete with
other county services, including clinical services for
indigent care, for fewer resources. Public-private
partnerships have been developed to cover gaps in some
jurisdictions, but these funds are only temporary and are
usually initiative-specific.
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d) Health Equity. According to the CDC, health equity is
achieved when every person has the opportunity to "attain
his or her full health potential" and no one is
"disadvantaged from achieving this potential because of
social position or other socially determined
circumstances." Health inequities are reflected in
differences in length of life; quality of life; rates of
disease, disability, and death; severity of disease; and,
access to treatment. Established in 2012, DPH's Office of
Health Equity (OHE) aims to reduce health and mental health
disparities in vulnerable communities. OHE's work is
directed through their advisory committee and stakeholder
meeting process. The OHE is required to consult with
community-based organizations and local governmental
agencies to ensure that community perspectives and input
are included in policies, strategic plans, recommendations,
and implementation activities. According to the U.S.
Department of Health and Human Services' report, "Healthy
People 2020: An Opportunity to Address the Societal
Determinants of Health in the United States," Americans do
not all have equal opportunities to make healthy choices.
A person's health and chances of becoming sick and dying
early are greatly influenced by powerful social factors
including education, income, nutrition, housing, and
neighborhoods. The "Healthy People 2020" report indicates
that if we, as a state, develop strategies and programs to
help more Californians become physically active and adopt
good nutrition practices, and create social and physical
environments that promote good health for all, California
could substantially improve health and reduce health care
costs.
e) Concept Paper. Additionally, a concept paper presented
this bill's proposal to develop a Health Improvement and
Innovation Fund, a funding and allocation structure to
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implement such an effort by providing resources for
community-based obesity and chronic disease prevention. In
addition to providing background for the proposal, the
paper identified principles for an investment in improving
the health and well-being of Californians by preventing and
mitigating the impact of chronic disease, including but not
limited to, size and scope of the funding commitment; focus
on primary, community-based prevention; a mix of
evidence-based and innovative approaches; and, allocation
to improve health in a manner that enhances health equity,
ensures a base level of resources in local communities, and
encourages efficient use. Finally, the paper also
identified expected outcomes in improving health and
reducing premature death and disability, catalyzing
partnerships, and building capacity for local health
agencies to reconfigure their activities to address the
most costly and burdensome health conditions.
f) Targeted federally funded programs. The largest
prevention program DPH administers is the Nutrition
Education and Obesity Prevention program, which provides
health education interventions to recipients of
Supplemental Nutrition Assistance Program (SNAP) benefits.
This program receives funding through the U.S. Department
of Agriculture, and had a budget of around $90 million in
2014-15. The mission of the program is to create
innovative partnerships that empower low-income
Californians to increase fruit and vegetable consumption,
physical activity, and food security with the goal of
preventing obesity and other diet related chronic diseases.
The Women, Infants, and Children program also offers
nutrition and breastfeeding education to program clients.
In federal fiscal year 2014, the CDC provided about $303
million to entities in California, including health
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departments, universities, and other public and private
agencies. Of this total, about $62 million of this funding
statewide was allocated to different entities for chronic
disease and prevention activities.
3)SUPPORT. The Health Officers Association of California (HOAC)
states that with sound policies and adequate funding, most
chronic illnesses (arthritis, asthma, cardiovascular disease,
diabetes, cancer, and depression) can be prevented. HOAC
contends that preventing chronic disease before it starts will
lead to decreased medical costs and improved productivity in
California.
4)RELATED LEGISLATION.
a) AB 2782 (Bloom) of 2016 imposes a health promotion a fee
of $0.02 per fluid ounce on bottled sugar sweetened
beverages and concentrates and establishes the Health
California Fund (Fund) and allocates moneys from the Fund
to various state departments for purposes of reducing the
incidence and impact of diabetes, obesity, and dental
disease in California. AB 2782 is pending in the Assembly
Health Committee.
b) AB 2430 (Gaines) of 2016 allows a taxpayer to designate
an amount in excess of personal income tax liability to be
deposited to the Type 1 Diabetes Research Fund, which the
bill would create. The bill would require moneys
transferred to the Type 1 Diabetes Research Fund, upon
appropriation by the Legislature, to be allocated to the
Franchise Tax Board and the Controller, as provided, and to
an authorized diabetes research organization, as defined,
for the purpose of type 1 diabetes research, as provided.
AB 2430 is pending in the Assembly Revenue and Taxation.
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5)PREVIOUS LEGISLATION.
a) AB 572 (Gaines) of 2015 would have required DPH to
create a detailed diabetes action plan for the state, and
to report the results of the plan to the Legislature
biennially. Requirements include the development of a
detailed budget blueprint identifying needs, costs, and
resources required to implement the plan and a proposed
budget for each action step, as well as policy
recommendations for the prevention and treatment of
diabetes. AB 572 was held on the Suspense File in the
Senate Appropriations Committee.
b) SCR 34 (Monning), Resolution Chapter 99, Statutes of
2015 proclaimed the month of September 2015, and each year
thereafter, as Childhood Obesity Awareness Month, and
expressed the Legislature's support of various programs
that work to reduce obesity among children.
c) SR 47 (Hall), Resolution Chapter 59, Statutes of 2015
proclaimed November 2016 as Diabetes Awareness Month, and
expressed the Senate's support of aggressive early
detection and treatment of diabetes.
REGISTERED SUPPORT / OPPOSITION:
Support
California Immigrant Policy Center
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California Pan-Ethnic Health Network
Health Access California
Health Officers Association of California
Opposition
None on file.
Analysis Prepared by:Kristene Mapile / HEALTH / (916) 319-2097