1.1 the st ate with the enactment of

1.1
Introduction

Local Health Departments protect the health of their communities by preventing disease and
promoting policies and systems to ensure that the populations they serve can achieve optimal
health. Local Health Departments (LHDs) typically provide clinical progr
ams and services such
as immunization services, screening for diseases and conditions, treatment of communicable
diseases, and maternal and child health services. Most local health departments also provide
population

based programs and services such as epi
demiology and surveillance, health
education, and environmental health services (NACCHO, 2016).

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LHDs are guided by the Ten Essential Public Health Services (Figure 1A) in the implementation
of their mission, core functions, programs, and services. These t
en essential services are: (1)
monitor health status to identify community health problems; (2) diagnose and investigate health
problems and health hazards in the community; (3) inform, educate, and empower people about
health issues; (4) mobilize communit
y partnerships to identify and solve health problems; (5)
develop policies and plans that support individual and com

munity health efforts; (6) enforce
laws and regulations that protect health and ensure safety; (7) link people to needed personal
health se
rvices and ensure the provision of health care when otherwise unavailable; (8) ensure a
competent public health and personal health care work

force; (9) evaluate effectiveness,
accessibility, and quality of personal and population

based health services; an
d (10) research for
new insights and innovative solutions to health problems
.

Several factors are forcing LHDs in California to redefine their roles and responsibilities for
improving population health. These factors are the implementation of the Patient P
rotection and
Affordable Care Act (hereinafter referred to as the Affordable Care Act or ACA) in 2010, the

expansion of Medi

Cal eligibility to 138% Federal Poverty Level in 2014, and the redirection of
indigent medical care funding from counties to the st
ate with the enactment of Assembly Bill 85
in 2013. In alignment with the Ten Essentials of Public Health Services, LHDs perceive
themselves as the primary institutions responsible for identifying and addressing their
community’s health concerns including
linking or providing care to medically underserved
populations. The residual number of uninsured people will challenge LHDs and force them to
identify which of the safety net services will be needed to maintain amidst decreasing funding
and increasing rest
rictions.

Since Local Health Departments are the entities charged with identifying unmet needs,
addressing gaps in service delivery, and reducing health disparities in their jurisdiction, LHDs
need information to understand their role and options in the de
livery of clinical services in the
era of healthcare reform. However, LHDs may lack the capacity to gather the data. Rural LHDs
in particular may lack the resources to obtain data on the impact of the ACA and their provision
of preventive services to the s
afety net population in their region. California has 58 LHDs
operated by counties, and 3 additional city LHDs operated by Berkeley, Long Beach, and
Pasadena. Of the 58 counties, 35 are considered rural as indicated by their participation in the
Counties Me
dical Services Program, which provides limited

term health coverage for uninsured
low

income, indigent adults that are not otherwise eligible for other publicly funded health
programs. Of these 31 small counties, 48% of them has populations less than 50,00
0 and the
remaining 52% has populations less than 200,000.

Like all other LHDs, these small LHDs need to understand their role in the new public health
system where more people are covered by health insurance, more people have access to
preventive health s
ervices, and where there may be a decreasing need of a ‘safety net’ for

medically underserved populations. However, small LHDs may lack the capacity to gather the
information about the effectiveness of services offered by other safety net providers, such a
s
Federally Qualified Health Centers, Rural Health Centers, private sector primary care providers,
and medical facilities in their jurisdiction. In a comparison of the workforce and training needs of
rural public health departments to those in suburban and

metropolitan areas, Hajat et al. (2003)
concluded that collaborative approaches and regionalization are needed in rural jurisdictions to
address the staffing shortage and program; and administrative training are crucial to promote
effective and efficient
delivery of public health services in rural areas. Since then, the ACA has
transformed the existing health care system by providing unprecedented investments in the
expansion of access to health insurance, community health centers, public health workforce,

health information exchange infrastructure, patient

centered medical home, accountable care
organizations, electronic health records, and prevention services. The passage and
implementation of the ACA is a driving force for change in the current public he
alth system
(Bovbjerg et al., 2011). The recommendations of ACA for successful navigation of the changing
landscape included evidence

base practice, defining value to foundational activities, and forming
partnerships with diverse organizations.

The impleme
ntation of the Affordable Care Act resulted in approximately 19.2 million
nonelderly people gaining health insurance coverage from 2010 to 2015 (Garrett et al., 2016). In
California, the ACA had expanded health coverage to millions of residents and improve
d
coverage for millions more; but between 2.7 and 3.4 million people under age 65 were predicted
to still remain uninsured by 2019, after the ACA is fully implemented. Of those predicted to
remain uninsured, approximately 50% remained ineligible for federa
l coverage options due to
their immigration status (Lucia et al., 2015). Proposed modifications to the ACA is expected to

increase the number of uninsured due to more restrictive Medicaid eligibility. The California
Department of Health Care Services noted

that the proposed American Health Care Act
represents a massive shift in costs to states, which will increase the burden on the state safety net
providers, and potentially increase uncompensated care costs in the populations of hundreds of
millions and po
tentially billions annually (Kent, 2017).

Under the current ACA, the Prevention and Public Health Fund expanded its access to primary
care services via increased its funding to primary care service providers such as Rural Health
Centers, Federally Qualifi
ed Health Centers, and school

based health centers. Various blogs,
briefings, and journal articles advocate reconsideration by public health departments to provide
clinical services. However, if the ACA is repealed or replaced in the future, the number of
uninsured will again increase and uncompensated costs will impact Local Health Departments.
While networking with their state health department, key federal agencies, and nearby county
health jurisdictions, Local Health Departments (LHDs) have the autonomy

to form local
collaborations and determine which health issues of particular concern and relevance to target
within their communities. Local Health Departments are aware of the need for evidence

based
strategic planning, especially as it pertains to ident
ifying the effectiveness of their existing
operations and developing partnerships with regional healthcare providers.

1.2
Current Situations in LHDs

Many LHDs lack the time and resources to identify efficient and cost

effective services that can
positive
ly impact vulnerable populations. A 2012 national survey undertaken by the National
Association of County and City Health Officials (NACCHO) found that, in 14 states including
California, 41% of LHDs had made significant cuts to staffing resulting in a red
uction of

population

based health services, such as population

based primary prevention and surveillance
(NACCHO, 2014). LHDs in rural areas may face additional constraints including shortages of
primary care providers, isolated communities, and lack of in
tegration in existing healthcare
providers. These constraints challenge underfunded and under

staffed the ability of rural LHDs
to find new ways to ensure that core public health services are delivered and effective.

In addition to the shifting landscape w
ith the implementation of the ACA, LHDs continued to
face funding and staffing challenges. A 2012 national survey undertaken by the National
Association of County and City Health Officials (NACCHO) found that 62% of California local
health departments (LHD
s) reduced or eliminated services in at least one program area; 20% of
LHDs reported continued cuts in immunization services; and more than one

third (36%) of
California LHDs lost at least one staff person due to layoffs or attrition in the previous year.
The
same study reported that California public health staff operated at a diminished capacity at 22%
of all LHDs, either because their hours were reduced or because they were furloughed.
Additionally, 24% of California LHDs expected their budget to be lowe
r in 2013, continuing the
trend of substantial percentages of LHDs experiencing budget cuts over the past five years
(NACCHO, 2013). Using 1997 and 2008 data, Hsuan and Rodriguez (2014) found that LHDs are
discontinuing clinical services over time. Those c
overing a wide range of core public health
functions are less likely to discontinue services when residents lack care access. They concluded
that future research is needed to examine the impact of ACA on the provision of clinical services
by LHDs, especial
ly in jurisdictions with residents still uninsured.

While the ACA offers expanded access to healthcare for vulnerable populations, particularly
preventive services, the impact in rural regions was unknown. One uncertainty is the number of
people who may co
ntinue to be uninsured by choice or by current eligibility restrictions. Similar

to the study by Lucia et al., the California Health Care Almanac, published by the California
Healthcare Foundation (2013) projects, indicates that one in five Californians wi
ll remain
uninsured. However, the data projections are limited to only socioeconomic factors, and do not
include county size or location. Likewise, the report of California’s Uneven Safety Net by the
Health Access Foundation in 2013 cites the CalSIMS proje
ction of 3

4 million Californians
remaining uninsured in 2019 and does not include projections of the uninsured in the 34 small
counties.

The Affordable Care Act established the Community Health Center Fund to provide $11 billion
over a five

year period fo
r the operation, expansion, and construction of health centers
throughout the country (HRSA, 2012). In addition to the $1.5 billion set aside for capital
improvements, funds are also provided to support primary care residency programs and the goal
of provi
ding high

quality and low

cost primary care. The additional investment is expected to
reduce some of the challenges previously faced by safety net providers in caring for the
uninsured, enhancing compensation for primary care providers, and expanding the c
ommunity
health center infrastructure. However, due to its size and location, small rural counties may not
have community health centers nearby; and thus, another uncertainty is the access to available
services due to limited capacity of Federally Qualifie
d Health Centers, Rural Health Centers, and
private primary care providers to accommodate the increased demand. In addition, as more
citizens acquire health coverage, more health professionals will be needed, especially in primary
care. Rural locations may

face increased competition for these professionals (Allen et al., 2013).
A review of the impact of national health insurance on childhood vaccination in Taiwan shows
that the increase in utilization of services is dependent on socio

demographics of the re
gion and
accessibility to services (Liu et al., 2002).

The implementation of ACA is forcing local health departments to define the value of public
health services and document gaps in the availability and accessibility of services due to the
changing lands
cape in funding. Because of these uncertainties, it is even more vital that all
LHDs, but particularly small LHDs, develop a clear sense of their role within the changed
healthcare environment and formulate innovative approaches that make the best use of e
xisting
resources in the provision of clinical services such as childhood immunization. Historically,
LHDs primary role in this arena is to ensure the timely and effective delivery of immunizations
services to children in their jurisdiction and direct deli
very of immunizations to vulnerable
populations (Ransom et al, 2012). Some of these activities are mandated by law, while others,
such as providing vaccinations through public health clinics, are the result of local decision
making. The estimated 94% of th
e population who will have insurance coverage beginning in
2014 may have immunization coverage as part of their package of care (Stewart et al., 2010).
Although the impact of the ACA on LHDs vaccination and immunization activities remains
unclear (Tan, 201
1), LHDs will still need to consider how to extend coverage to those sectors of
the population who will not be covered by the ACA, i.e., the undocumented workers and people
who refused to buy private insurance.

1.3 An Urgent Need Identified in LHDs

Part
of the calculation regarding the most effective and cost

effective way to provide services is
the extent of cooperation that the LHD will have with healthcare providers in their jurisdiction.
These providers, such as community health centers and school

bas
ed health centers, have
received additional ACA funding, and expected to gain prominence in delivering primary care
services to vulnerable populations. This creates new opportunities for LHDs to collaborate with    

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