HomeMy WebLinkAbout04152004-CC-Jeffco Bd of HealthJEFFERSON COUNTY BOARD OF HEAl.TH
MINUTES
Thursday, April 15, 2004
Board Members:
Dan Titterness, Chairman - Coun(y Commissioner Dis#ict # !
Glen Huntingford- Coun[y Commissioner Dist~ct #2
Patrick M. Rodgers- Coun(y Commissioner Dis#ict #3
Geoffrey Masci - Port Tomnsend Cify Council
Jill Buhler- Hospital Commissioner Distffct #2
Sheila lT?esterman - Citizen at La~ge (City)
Roberta Frissell, Vice Chairman - Citizen at Large (Coun[y)
Staff Members:
Jean Bald~vin, Health (_v' Human Services Director
Larry ?ay, Environmental Health Director
Julia Danskin, Nursing Services Director
Thomas Locke, MD, Health Offcer
Ex-oflcio
David Sullivan, PUD # !
Chairman Tittemess called the meeting to order at 7:00 p.m. in the Jefferson General Hospital
Auditorium, Port Townsend, Washington. All Board and Staff members were present. There was a
quorum.
City Council members present: Frank Benskin, Kees Kolff, Geoff Masci, Freida Fenn, Catharine
Robinson, Laurie Medlicott.
Guests: Luke Boges, Peninsula Daily News; Janet Huck, The Leader; Beth Wilmart, Jefferson
County Community Network; Paula Dowdle, Jefferson General Hospital; David Goldsmith, Alan
Sartin and Qwen Zorrah, Jefferson County; Pam Kolacy, Corine Stem and David Timmons, City of
Port Townsend.
APPROVAL OF MINUTES
Member Masci moved to approve the minutes of March 18, 2004. Vice Chairman Frissell
seconded the motion, which carried by a unanimous vote.
PUBLIC COMMENT
Beth Wilmart, Program Manager with Jefferson County Community Network talked about how the
Health Department's early intervention Maternal Child Health Services (nurse home visiting
program, breast feeding support) support their program goals of working with community members
to prevent child abuse and neglect, youth substance abuse, and domestic violence.
APPROVAL OF AGENDA
Member Masci moved to approve the agenda as submitted. Vice Chairman Frissell seconded
the motion, which carried by a unanimous vote.
HEALTH BOARD MINUTES - April 15, 2004 Page: 2
OLD BUSINESS AND INFORMATIONAL ITEMS
Letter from Carl Osaki, Washington State Board of Health: Chairman Tittemess read Mr.
Osaki's letter acknowledging concerns expressed by the Jefferson County Board of Health regarding
sewage releases from vessels as well as the request that the State Board of Health hold a public
forum on whether existing practices and regulations provide adequate health protections. The
response also indicates the State Board of Health's intent to monitor the Memorandum of
Understanding's impact on cruise ship wastewater management practices and to hold a follow-up
briefing on December 8, 2004. Dr. Tom Locke agreed to inquire with the State Board of Health
about how frequently monitoring would occur and then report back to the Board.
NEW BUSINESS
Special Meeting with the Port Townsend City Council
"Sharing Responsibility for Public Health"
Chairman Tittemess opened the joint meeting by recognizing the financial challenges facing all
levels of government as well as the various duties prescribed under the RCWs. He noted that the
expanded Board of Health - with County Commissioners, City Council, Hospital Board
representative and citizens at large - has operated much like a Health District and has a broader
agenda than the services required or mandated by the County.
Welcome/Introduction: Paula Dowdle, Chief Operating Officer for Jefferson General Hospital,
and Member Buhler welcomed the City Council and Board of Health to the Hospital Auditorium.
Member Buhler talked about the Hospital District's mandate to provide emergency services to all
members of the community regardless of their ability to pay and the Hospital Commission's
extension of this mandate to ensure the availability of basic health care. With over 70% of all
hospital patients being Medicare or Medicaid insured, the dependence on strangulated federal
fimding has impacted the hospital and local practices alike. She explained how Jefferson General
addressed funding challenges by partnering with and subsidizing doctors by paying a flat fee for
each patient treated and taking advantage of a critical access hospital program that pays cost-based
reimbursement. A long-term solution is still being sought and will require partnering and
collaborating with other entities such as is occurring between the Hospital Board and the expanded
Board of Health, which includes the County Commissioners.
The Crisis in Public Health Funding: Dr. Locke noted that the agenda packet included a
significant amount of background information about public health services. In speaking of the
tradition of partnerships among the public health community, he noted that funding in this State has
always been a joint responsibility. Legislative actions in 1993 attempted to solve a perceived
problem by taking money from cities and giving it to counties, absolving cities of the responsibility
for public health. But since legislative actions ftu~er reduced this source, funding for public health
has become extremely uncertain and the stability of public health has decreased.
HEALTH BOARD MINUTES - April 15, 2004 Page: 3
Member Westerman asked why the legislature had changed the historical relationship between cities
and counties? Dr. Locke explained that they had hoped that redirecting the funds would produce a
long-range solution. As funding was done differently from year to year in different jurisdictions, the
Motor Vehicle Excise Tax (MVET) was thought at the time to be a more stable funding source.
Noting that he would deliver the infamous "train wreck" presentation to the City Council on April
26, David Goldsmith provided background about MVET funds, which came out of Referendum 48.
While citizens voted for this referendum, the funding source was later changed. The local impact is
that because the County fundamentally is funded by property taxes (which are capped at 1%), it is
unable to grow to keep up with inflation. While there is growth due to new construction and some
increase in sales tax, this provides only about 20% of the total revenue source. For this year,
Jefferson County citizens' portion of the local public health department's $3.5 million program
budget was $450K. In order to maintain even a decreased level of service, the County had to take
money out of reserves from prior years and put it into this year's budget. He noted that about $70-
80K in reserves that was used to fund this year's budget would not be available for 2005. Given that
the $450K is also not likely to expand and because ongoing contract negotiations are likely to raise
labor costs to some degree, and that personal healthcare insurance premiums have increased, it is
certain that the Health Department's delivery of services will be impacted. He recognized that the
City has been a great parmer in dealing with regional services and that despite the revenue issues
they both face, the City and County continue to have a good working relationship.
Commissioner Huntingford noted that this is the first time the County has used reserve money for
ongoing expenses, an act that was thought to be unsustainable. While the Commissioners felt the
programs were so important to keep going this year and that grant funds are being stretched as far as
possible, the County is not only asking the City to help with funding, but also with program
prioritization.
Jean Baldwin then reviewed graphics showing a breakdown in revenue, which since 1994 has
remained relatively flat at $400K, and explained how grant funds are matched and leveraged.
Long-term Solutions: Dr. Locke and Jean Baldwin reported that this problem is not unique to
Jefferson County, but is a statewide problem. Starting and abandoning programs because of a lack
of funding is also very costly and an ineffective way to improve community health. It is known that
the solution - a stable source of funding - must come statewide. The discussion between Council
and Board is not to make decisions on long-term solutions, which would come from action
throughout the state, but to find short-range solutions. Dr. Locke further explained that the State has
authority to levy property tax in excess of what they actually use, which was the previous source of
funding.
Asked what the hospital would do if patients start coming to them for services no longer offered by
this or other health departments, Paula Dowdle responded that the hospital is already seeing an
increase in the need for services from local citizens. Noting that the Hospital had taken over
childhood immunizations two years ago, she said that they would face even greater demand if other
programs were not funded. Ms. Dowdle said that while they do not have a huge influx of out-of-
county residents at this time, if they did, it would be disastrous because the hospital is mandated to
see all patients. Jean Baldwin added that the Health Department traditionally refers individuals from
HEALTH BOARD MINUTES - April 15, 2004 Page: 4
outside of the County to their own County Health Department. Member Buhler said she does not
believe there is a policy for expanded services but she personally would not support treating
individuals from other areas if it meant putting our own community members at risk.
Asked by Catherine Robinson about the basis for his optimism about long-term solutions, Dr. Locke
referred to Winston Churchill's observation that Americans always do the right thing - after they
have exhausted all other alternatives. While he would not now characterize himself as optimistic
about 2005, it depends on how bad things get. A collapse of health departments even in rural
Eastern Washington is not insignificant. The public health system, especially in communicable
disease control, is only as strong as its weakest link. He noted that public health is extraordinarily
efficient, using about one percent of healthcare dollars. The Tri Association of Cities and Counties
would pursue legislation for long-range funding.
Using the concept of triage, David Sullivan said it would seem that you would need to prioritiZe the
people's most vulnerable needs first and then really work for that long-term solution. He referred to
the Oregon Health Plan, where they number and prioritize what gets paid for with the plan. They
say, "We can afford up to 240 conditions and after that we cannot fund it anymore." The next year,
maybe it is up to 238 and those other two just don't get treatment. It seems like you would have to
do that in the short term for this kind of public health need and look at the whole budget. He is
concerned about pinning parts of the budget against each other.
Jean Baldwin said that the League of Women Voters recently held a long, informal discussion about
the fact that government help will always be needed by those who are in trouble or who are at the
highest risk (law and justice, jail costs, some prevention). It is really a leap of faith to believe that
good, science-based, absolutely clear prevention reduces child abuse and the number of kids in
foster care raises literacy and increases quality of health. Prevention is cheaper than jail.
Chairman Tittemess said he believes it has been the goal of the Board of Health to provide those
preventive services to the best of our ability. While it doesn't fit in that narrow category of
mandated services it is a County Health Department that actually operates as a greater community
health district.
Findim, a Short-Term Solution: Referring to the written 2004 Community Health Budget and
Proposal formulas, Jean Baldwin and Dr. Locke explained that the intent was to show the
proportional use of services by the City. The figures reflect only the Nursing Program, which is the
section having the largest community impact with prevention. The tables showed the current local
general fund contribution in these program categories and the discrepancy between revenue received
and the actual costs of the services. Both the "population-based" and "assessed property value"
formulas show the total program subsidy, the percent of Port Townsend users, the City's share of the
subsidy, less the City's current share to arrive at the City unfunded share. These formulas are two
rational ways to look at the proportional use - how many City residents use services relative to non-
city residents - and a look at crediting City residents for the support they currently provide through
County property taxes. It is not surprising that there is a high rate of use by those actually living
within the City limits. Staff confirmed that the City was included in the County population and the
fair market value figures.
HEALTH BOARD MINUTES - April 15, 2004 Page: 5
Dr. Locke pointed out that if you were to try to cut $150K from the budget, you would begin to see
how funding is being leveraged and balanced with matching funds. The removal of a small amount
of funding for the Communicable Disease program would likely mean there would be no
communicable disease control. He then described the four forms of public health jurisdictions -
single county health departments, single county health districts, multi-county health districts (four in
the State), and city/county health districts. The only structure that would apply to Jefferson County
would be a city/county health district, because of the needed threshold population of about 100,000.
He noted that until 1977 Jefferson and Clallam Counties comprised a health district (Olympic
Health District).
Kees Kolff then asked Dr. Locke to comment on Clallam County's public health funding and why
the multi-health district did not continue? Dr. Locke responded that Clallam County has been
running on reserves for the last two years and is facing a crisis similar to Jefferson County. Several
Clallam County programs are less ambitious, such as their early intervention child services. In
February, Clallam County Commissioners voted to enlarge the Board of Health for the primary
reason of expanding the base of support for public health. David Goldsmith recalled that the reason
behind dissolving the multi-county district had to do with service delivery issues, differing needs,
and accountability of staff. Environmental Health was the biggest program and there were not a lot
of prevention services.
Vice Chairman Frissell said that she cannot remember one time in her six and half years on the
Board when there was any kind of dichotomy between City versus County. It is a Board of Health
for everyone who lives here and even though three of the seven members represent City residents,
the Board never discusses services in terms of City or County.
Addressing the question of how program priorities would be set, Jean Baldwin said the Board of
Health has governing authority. David Goldsmith agreed that the Health Board sets the program but
the County Commissioners have said they cannot deliver the amount of money necessary to carry all
of the programs. So options are to either change program services delivery or change the pie of
funding.
Chairman Titterness clarified the Board of Health did not expect decisions from any entity tonight.
The purpose was to convey information, answer questions and discuss possible solutions.
Member Masci proposed that a health district has been discussed previously as a long-term solution.
Recognizing the separate City and County flat revenue situations, he said for the City to make cash
contributions it would have to either offer diminished levels of service or cut services or personnel
across the board (close the pool or lay off two people). The County faces similar issues. He also
talked about how cuts in State funding are negatively impacting the City, who has the least capacity
to increase its revenues. Looking beyond jurisdictional boundaries, he believes there needs to be a
discussion, including the hospital, of the expected levels of service. He proposed that the City first
recognize the need for sharing the responsibility for public health and at least make a moral
commitment to a work_group to craft short-term and long-term solutions even if it means lobbying in
Olympia. If the City can find the funding, they would need assurances that the money would be
allocated and deposited to the appropriate fund rather than the general fund. David Goldsmith noted
there is a general fimd contribution to public health, but the Health Department is a separate fund
HEALTH BOARD MINUTES - April 15, 2004 Page: 6
that stands by itself.
Commissioner Huntingford agreed that it all comes down to level of service. Each time there is a
discussion of regional services, the issue of what services City residents - as County residents - are
entitled to arises. Jean Baldwin noted that in the East, every Township, County, City has a Health
Department. She believes the County Health Department is as small as a Health Department should
ever be and still there are many oppommities for State and Regional collaboration.
Kees Kolff asked if there has been consideration of again sharing services with Clallam County and
going back to a multi-county district? Dr. Locke said that while there has not been serious
discussion of a multi-county district, from a service delivery standpoint, such as emergency
preparedness, the two already share staff and resources. There has also been support from the Board
of County Commissioners of both counties to provide services in the most efficient way.
Commissioner Rodgers, while not proposing what would amount to a merger, pointed out that State
law does permit a unified City/County with one Public Works, Health Department, Planning, etc.
Freida Fenn said it seems easy to make the commitment to coming up with a vision of a long-term
solution and added that she would also like to see all elected officials from the County drive to
Olympia. She was not confident that there would be federal assistance. She agreed it does not feel
good to be the last and smallest taxing authority on public health. She saw several possible options,
none of which she liked: 1) Merge Jefferson and Clallam Health Departments, 2) County covers the
shortfall and cuts services in other areas, 3) County raises taxes - making its case and going to the
voters, 4) City pays its suggested $130-$150K share, with the consequence being that the City
would have to cut the same amount of City services, 5) City raises taxes and they would have to put
it on the ballot - in which case she would want to see more representation of the City on the Health
Board, and 6) Let services collapse, go through triage, and take the crisis lobbying to the State and
Federal governments. She would like more options to add to the list.
Member Masci added the option of banked capacity.
Chairman Tittemess agreed that merging City and County governments could make a health district
and other services more efficient. There might not be the political will to do it in our community,
but it could be a practical solution and should be put before the voters.
Freida Fenn commented that she sees this as a long-term solution.
Kees Kolff asked if there are less drastic ways to share services and resources? He noted that City
Manager David Timmons has provided the Council with the list of ways in which the City has been
increasing its contribution to regional services. He reported that since 1996, the City's share of
services has gone up from $200K to $800K a year, which includes picking up the pool, jail, and
other things. If deciding an appropriate relationship between the City and County with regard to
health services, all services should be examined - recreation included - so that a partnership in
health be consistent with the other ways in which we are partnering. He is in favor of the City and
County working together to figure out how to solve the problem because he believes it is a critical
service.
HEALTH BOARD MINUTES - April 15, 2004 Page: 7
David Sullivan noted that the PUD is getting ready to spend money on more treatment at its
Sparling well and reminded the Board that there is a proposal to the City to instead buy water
wholesale from the City, which might provide it with an estimated $100K in additional revenue.
Member Westerman recalled that when she was on City Council, in the late 1980s, the City was
contributing to the County public health. When the legislature took away the MVET money and
gave it to the Counties for public health, it eliminated conflict by taking public health out of politics.
The reason she believes the County Commissioners were brave enough to expand the Health Board
was because they also believed that public health should be taken out of the realm of politics. When
the legislature took away the MVET money to fund public health, the County was left to pay the
salaries of all the nurses at the Health Department that were giving immunizations to children of
City residents. The Department has done a great job of providing preventative public health services
that in the long term will save all of us money. While the City of Port Townsend has had a lot more
courage to do so in the past, it needs to recognize that it has a responsibility to look at ways of
generating revenues to address needs of the community. The County needs to look at raising more
money through property taxes; the City needs to look at ways to support these and other services-
such as the pool and recreation - that serve City residents. She is nervous about putting this to a vote
of the people, because the vote of the people on their license tabs is what got us into this situation.
She does not believe that combining positions would solve the problem, nor does she believe it's
possible to have one person necessarily do two positions. She does not want to see the elimination
of programs that we have spent ten years building.
Commissioner Huntingford said he could provide a history lesson about how the City got the pool.
We need to decide what City residents are really paying for with their tax dollars. The County might
have the ability to raise property taxes and in certain cases, it can raise sales tax but it currently does
not have the City's ability to raise taxes for utilities and other things.
Chairman Tittemess said that from the County Administrator's explanation, you would understand
that even if the County raised taxes and took the whole 13% of banked capacity next year it would
be back in the same situation in a few years.
Member Masci responded that while the City appreciates David Sullivan's offer, he noted the City
currently does not have a secure water fight.
Laurie Medlicott said it does not really matter whether as a citizen she is going to pay for services
through the City or the County, the fact is that if she wants that health service she has to pay for it.
She would like to redirect the discussion to how we as elected leaders can justify these expenses to
the public as necessary to the community's health and presenting them with their options for paying
for it.
Member Buhler agreed, saying if we can agree that public health is our number one priority, we can
begin other discussions. How we get there is up to the entities.
City Manager David Timmons said this issue has been a debate since he arrived. While he does not
have a lot of history here he has the advantage of having seen how it is done elsewhere. He has also
worked in a State where there were no counties. His advice was that the formula should not break
HEALTH BOARD MINUTES - April 15, 2004 Page: 8
out City residents as a different form of service client than anyone else. It should just be a county
system. II'we are going to talk about the City paying as a taxing jurisdiction, then we should also
consider other taxing authorities such as the School District, the PUD, and Port because they all
have a relative tax burden, obligations and duties. As a professional, he looks at the duties and
responsibilities of the City as a jurisdiction and whether we are meeting those obligations. The City
is also headed toward a similar train wreck and finding it hard to maintain their infrastructure given
their $500K to $750K operating deficit. A shift of funding might solve this problem but create a
problem somewhere else. In some respects, he agrees we need to look at structural changes. Tonight,
the Parks District Task Force is going to be finishing its work and would be reporting to council on
the possibility of raising taxes in the City to support park services. If we were to consolidate all park
services within the City as a City service, the County would be relieved of the liability for its in-city
park services and be able to use the savings to meet its obligations to the Health Department. The
challenge would be to find a way to make the funding fit within the statutory framework.
Chairman Tittemess said the scope of the statutory requirements of the Health Board and Health
Department are not what we are talking about tonight, but rather the scope of the services that we
provide. The Health Board effectively representing the City's position has been advocating for these
additional services and so that is something that should be clearly defined. What we are working
against is not the narrow scope of required services of the County Health Department, but those
things that are preventative that we want to do within the community.
Manager Timmons said the County has a tremendous wealth of assets and resources, but the biggest
problems we have are institutional barriers. There is a need to address the concerns of the youth for
recreation access within the community. For example, they have a community center that youth
cannot get access to not because of a conflict but because of an institutional barrier. The Parks
District is just one option on the table.
Frank Benskin asked about the Health Department's timeframe for a change in services? Jean
Baldwin noted that as of July 1st, the maternal child health federal grant would be lost and the
department would be going into a program revision and would begin layoffs in July. At the end of
May, she would need to decide whether to send out layoff notices. Frank Benskin confirmed that
incremental payments might also be possible.
Kees Kolff noted that Michelle Sandoval could not be here tonight due a conflicting meeting. He
would like to take this issue back to Council for further discussion.
David Sullivan said there is a lot of giving in the community and there might also be opportunities
for a public/private partnership.
Laurie Medlicott asked if and when this issue comes before the Council for consideration, she
assumes there would be some sort of packet of information that would include an explanation as to
why this didn't get brought to the City's attention before it became a sudden emergency? David
Goldsmith responded that he had authorized the spending down of reserves to build a year of
transition until Federal and State impacts for funding maternal child health were fully understood.
The real crisis will come in 2005.
HEALTH BOARD MINUTES - April 15, 2004 Page: 9
When Member Masci asked what would be needed to keep matemal child health going until
December 2004, Jean Baldwin indicated it would be roughly $40K. Chairman Tittemess recognized
Jean Baldwin's excellent job as Department Manager in a difficult situation.
ACTIVITY UPDATE/OTHER ANNOUNCEMENTS - None
AGENDA PLANNING/ADJOURN
The meeting adjourned at 9:00 p.m. The next meeting will be held on Thursday, May 20, 2004 at 2:30
p.m. in the Conference Room of the Jefferson County Health Department.
JEFFERSON COUNTY BOARD OF HEALTH
Dan Titterness, Chairman
Jill Buhler, Member
Roberta Frissell, Vice Chairman
Sheila Westerman, Member
Geoffrey Masci, Member
Glen Huntingford, Member
Patrick M. Rodgers, Member