HHS13 Create a State Public Health Officer to Strengthen Public Health in California
Summary
California's public health system has been criticized for inadequately protecting the public's health. Creation of a statutorily identified state public health officer is a key step in improving the effectiveness of California's public health system and protecting the public's health through coordinated leadership and science-based decision-making.
Background
Public health is the science and practice of protecting and improving the health of a community through preventive medicine, health education, control of communicable diseases, application of sanitary measures, and monitoring of environmental hazards. Public health focuses on the health of communities rather than individuals, emphasizes prevention of illness over treatment, and recognizes multiple determinants of health beyond individual behavior.
The core functions of public health are to assess and monitor the health of communities, formulate public policies designed to solve health problems and determine priorities, and assure that all populations have access to appropriate and cost-effective care.[1] Public health carries out these core functions through ten essential services. (See Exhibit 1.)
| Core Function | Essential Public Health Services |
|---|---|
| Assessment |
|
| Policy Development |
|
| Assurance |
|
Exhibit 1. Source: Centers for Disease Control and Prevention, Public Health Functions Steering Committee, 1994.
Life span in the United States increased 30 years in the 20th century. Although this increase is often attributed to medical science and individual health care, advances in public health are responsible for 25 of the 30 years gained.[2] Because of public health, people can eat at restaurants and drink water without becoming ill, vaccinate their children to prevent debilitating diseases, and they know that wearing seatbelts, not smoking and maintaining a healthy weight will prevent premature death.
Public health has the responsibility for preparing for and responding to emerging issues that threaten the public's health. In recent history, the world has seen outbreaks of new illnesses such as AIDS, SARS and West Nile Virus and experienced the heightened threat of terrorist acts that may use biological agents such as anthrax and smallpox. The public is often fearful of these threats, and public health personnel lead our communities in prevention and response.
Public health plays a critical part in containing health care costs. According to the Centers for Disease Control and Prevention, cardiovascular disease, cancer and diabetes are the most costly, prevalent and preventable health problems in the United States.[3] Chronic diseases account for 70 percent of all deaths in the United States and more than 75 percent of the $1.4 trillion in medical care costs.[4] In California, health care is the leading industry at $150 billion per year, representing about 10 percent of the state's economy.[5] By integrating public health prevention, the health care system can reduce disease, improve quality of life, prevent premature death and reduce health care costs.
Criticisms of public health
Despite all that public health has achieved and can accomplish, several reports have criticized the public health system and questioned whether its infrastructure and lack of coordination and preparedness impair its ability to protect the public's health. In 1988, the Institute of Medicine reported that the nation's public health system was in trouble, had lowered vigilance, and faced competing priorities from ongoing preventive efforts and emerging threats such as AIDS and environmental toxins, all of which ultimately threatened the public's health.[6] The Institute followed up in 2002 with a report on public health in the 21st century and described how the real and perceived anthrax threats in 2001 revealed the vulnerabilities of the public health system due to political neglect, absence of science-based decision-making and outdated surveillance and communication systems.[7]
California's public health system has been criticized by internal participants and external reviewers. The California Conference of Local Health Officers asserts that public health has suffered from decades of neglect and cites examples of ill preparedness, such as California learning of an E. coli outbreak from Washington State; a widely criticized agreement with the U.S. Department of Agriculture about recalled meat products that prohibited sharing of certain information with local health departments; and problems with bioterrorism preparedness.[8] The Little Hoover Commission issued a report in 2003 that identified the state's public health system "as the weakest link in California's homeland defense."[9] At the Commission's request, RAND Health conducted an assessment of gaps in California's public health system.[10] The study results present a picture of uneven public health preparedness where a California resident's health and safety related to a major disease outbreak or act of bioterrorism will vary from county to county. The report also pointed to varying capabilities among counties to provide teen pregnancy prevention services and trace contacts of individuals with sexually transmitted diseases. The report also notes poor coordination between the state and counties.[11] The report states that there appears to be an absence of state leadership and local health departments must fend for themselves.[12]
These organizations provide multiple recommendations to address the identified problems, all of which highlight the need for clear public health leadership. Both Institute of Medicine reports and the California Conference of Local Health Officers state the need for public healthtrained physician leadership, which California does not require.[13] The RAND Health study identified leadership qualities of health officers as an important factor in public health's preparedness.[14]
California's public health system
In California, county boards of supervisors must appoint local health officers to lead and protect the health of their communities.[15] Local health officers, unlike any other medical practitioners, have police powers they can exercise to protect the public health, and they can take any preventive measure necessary to protect the public from any public health hazard during declared emergencies.[16] Commensurate with the level of responsibility it gives to local health officers, California law requires that they be physicians.[17]
Several state departments have public health functions, but the California Department of Health Services (DHS) is responsible for administering and enforcing most public health laws and programs. The department advises local health authorities and, when it determines that public health is threatened, can control and regulate their actions.[18] Despite the department having these considerable powers, state law does not require the appointment of a state public health officer.[19] Public health emergencies know no geopolitical boundaries, and one report revealed a troubling situation where understanding of public health legal authority varied greatly across local health jurisdictions; however, the state has no similarly credentialed counterpart to the local health officers to advise the Governor and ensure that the state appropriately exercises its emergency powers.[20]
The Little Hoover Commission issued a report in April 2003 recommending that public health functions be led by a physician and practice science-based leadership.[21] The California Conference of Local Health Officers supports the concept of physician leadership on public health issues, emphasizing that medical expertise is critical for "sound interpretation and rational enforcement" of public health laws, "lends the necessary authority and credibility to lead and guide" public health efforts and is "grounded in collegial and professional respect" in the relationship between public health officials and other physicians and medical organizations.[22] The Institute of Medicine's 1988 report on public health also recommended that public health functions be under the leadership of a person with public health training and doctoral level education as a physician (or in another health profession).[23] According to a national survey, 23 states and territories require the lead health official to be a physician.[24]
The department has attempted to identify a state health officer in various ways. When the director has been a physician or other trained health professional, the department has designated that person as the state health officer. When the director has not been a trained health professional, the department designated a physician elsewhere in the department or has recruited and appointed an individual to serve in that capacity. The current health officer is an assignee from the Centers for Disease Control and Prevention. However the position has no statutory or regulatory existence or authority, which translates to an absence of authority and accountability for the exercise of police powers.[25]
The salary California currently pays for top officials may be inadequate to attract and retain a qualified state public health officer. For purposes of comparison, the California Government Code sets the annual salary of the director of DHS, which is currently $117,386.[26] According to a national survey, this puts California in the bottom 21 states and territories.[27] In contrast, several local health officers in California can earn salaries that exceed that of the CDHS director. The health officers in Stanislaus and Placer counties can earn salaries that approach $200,000 and the health officer for the City and County of San Francisco can earn a salary in excess of $216,000.[28]
Recommendations
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The Governor should work with the Legislature to consolidate all core public health functions into one newly created organization under the direction of a state public health officer.
The state public health officer should have necessary qualifications (education, credentials, experience and leadership) and a clear role, responsibility, authority and accountability solely focused on public health. By creating the position, the state avoids having to delegate this important function to someone borrowed from the ranks or another governmental entity. The position should have exempt status to permit recruitment from outside of the state's civil service system.
The state public health officer would provide professional and technical leadership to the medical and scientific professionals serving in DHS and local public health departments. The incumbent would work with local health officers, schools of public health, and health care systems on prioritizing and planning of public health services, establishing public health policy and forging a strong public health network. Most importantly, the state public health officer would provide the medically-based rationale and responsibility in recommending and exercising considerable police powers in a public health emergency and work in close partnership with local health officers and the federal Centers for Disease Control and Prevention.
The state public health officer would be the chief communicator on public health issues to the general public and health professionals. Such a person would be more credible if he or she has medical training and public health expertise. The incumbent would strengthen public health's role in assuring the conditions for population health, working in partnership with employers and businesses, the media, academia, the health care delivery system, and communities.[29] California's public health officer would provide and advocate for science-based, public health decision-making with policymakers, promote understanding of the multiple determinants of health and mobilize and support communities in developing and sustaining solutions to health problems. This person would be the key link in forging the relationships and providing the leadership necessary to make public health a priority equal to public safety.
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The Department of Health Services, or its successor, should establish a competitive salary for the state public health officer.
The state will have difficulty recruiting a public health officer without establishing a salary commensurate with the desired qualifications. The state should conduct a salary survey of local health officers and key officials in California's schools of public health and compare them with the salaries of health officials across the nation to determine the appropriate salary to recruit a trained, experienced public health physician to serve in the capacity of state public health officer.
California has already set a precedent to establish a higher salary for a medically trained individual in a critical position. The Department of Mental Health has an assistant director of Clinical Services with a maximum salary range of $178,608.[30] This position is a career executive assignment, and the incumbent serves as the department's highest level medical consultant and must be a board approved physician.
Fiscal impact
Although a salary survey is recommended, the costs below presume hiring a public health officer effective July 2005 at an annual salary of $200,000 plus 30 percent for benefits and $15,000 for annual operating expenses. Though a robust public health system will save health care costs and increase years of useful life, the savings cannot be quantified.
General Fund
(dollars in thousands)
| Fiscal Year | Savings | Costs | Net Savings (Costs) | Change in PYs |
|---|---|---|---|---|
| 2004-05 | $0 | $0 | $0 | 0 |
| 2005-06 | $0 | $275 | ($275) | 1 |
| 2006-07 | $0 | $275 | ($275) | 1 |
| 2007-08 | $0 | $275 | ($275) | 1 |
| 2008-09 | $0 | $275 | ($275) | 1 |
Note: The dollars and PYs for each year in the above chart reflect the total change for that year from 2003-04 expenditures, revenues and PYs.
Endnotes
[1] Institute of Medicine of the National Academies, "The Future of Public Health" (Washington, D.C., National Academy Press, 1988), pp. 7-8, http://books.nap.edu/books/0309038308/html/index.html (last visited June 9, 2004).
[2] Centers for Disease Control and Prevention, "Ten Great Public Health Achievements-United States, 1900-1999" "Morbidity and Mortality Weekly Report" (April 2, 1999), http://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm (last visited April 29, 2004).
[3] Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, "Chronic Disease Overview," http://www.cdc.gov/nccdphp/overview.htm (last visited May 17, 2004).
[4] Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, "Chronic Disease Overview."
[5] Dan Walter, "Medical Politics and Money, from HMOs to Dogs' Teeth," "Sacramento Bee" (June 9, 2004) p. A-3.
[6] Institute of Medicine of the National Academies, "The Future of Public Health" (Washington, D.C., National Academy Press, 1988), pp. 1-2.
[7] Institute of Medicine of the National Academies, "The Future of the Public's Health in the 21st Century" (Washington, D.C., National Academy Press, November 2002), p. 3, http://www.nap.edu/catalog/10548.html (last visited June 9, 2004).
[8] Letter from Scott Morrow, M.D., M.P.H., president, California Conference of Local Health Officers, to California Performance Review (April 13, 2004).
[9] Letter from Michael E. Alpert, chairman, Little Hoover Commission, to Governor Gray Davis and Members of the Legislature (April 10, 2003).
[10] Little Hoover Commission, "To Protect and Prevent: Rebuilding California's Public Health System" (Sacramento, California, April 2003), p. 3.
[11] Dorsey Griffith, "Study: Counties' Readiness Varies for Health Crisis," "Sacramento Bee" (June 2, 2004) p. A-5.
[12] Testimony from Nicole Lurie, RAND Corporation, RAND Health, to the California Senate Committee on Health and Human Services, Sacramento, California, June 2, 2004, p. 5, http://www.rand.org/publications/CT/CT227/CT227.pdf (last visited June 10, 2004.)
[13] Institute of Medicine of the National Academies, "The Future of Public Health" (Washington, D.C., National Academy Press, 1988), p. 11; Institute of Medicine of the National Academies, "The Future of the Public's Health in the 21st Century" (Washington, D.C., National Academy Press, November 2002), p. 415; letter from Scott Morrow, M.D., M.P.H., president, California Conference of Local Health Officers, to California Performance Review (April 13, 2004); and Little Hoover Commission, "To Protect and Prevent: Rebuilding California's Public Health System" Sacramento, California, April 2003), p. 30.
[14] Nicole Lurie, Jeffrey Wasserman, Michael Soto, Sarah Myers, Poki Namkung, Jonathan Fielding and Robert Burciaga Valdez, "Local Variation in Public Health Preparedness: Lessons from California," "Health Affairs" (June 2, 2004), http://content.healthaffairs.org/cgi/content/full/hlthaff.w4.341/DC1 (last visited June 10, 2004).
[15] Health and S. C., Section 101000. Health and S. C., Sections 101025-101070 outline the major responsibilities and authority of the local health officers.
[16] Health and S. C., Section 101040.
[17] Health and S. C., Section 101005.
[18] Health and S. C., Section 100180.
[19] Association of State and Territorial Health Officials, "2002 Salary Survey of State and Territorial Health Officials" (Washington, D.C., 2002), Chart E. The 51 respondents represented 49 of the 50 states, the District of Columbia and Puerto Rico.
[20] RAND Corporation, RAND Health, "Public Health Preparedness in California, Lessons Learned from Seven Health Jurisdictions" (Santa Monica, California, 2004), p. 40 (pre-publication copy). http://www.rand.org/publications/MG/MG247/MG247.pdf (last visited June 9, 2004).
[21] Little Hoover Commission, "To Protect and Prevent: Rebuilding California's Public Health System" (Sacramento, California, April 2003), p. iii.
[22] Letter from Poki Stewart Namkung, M.D., M.P.H., President, California Conference of Local Health Officers, to Hattie Rees Hanley, Little Hoover Commission (February 6, 2003); and California Conference of Local Health Officers, "CCLHO Responds to the Recommendations from Little Hoover Commission Report," Sacramento, California, January 8, 2004, p. 1 (briefing document).
[23] Institute of Medicine of the National Academies, "The Future of Public Health" (Washington, D.C., National Academy Press, 1988), p. 11.
[24] Association of State and Territorial Health Officials, "2002 Salary Survey of State and Territorial Health Officials" (Washington, D.C., 2002) p. 1.
[25] Interview with Eileen Eastman, California Department of Health Services, Sacramento, California (March 15, 2004); and interview with Kevin Reilly, California Department of Health Services, Prevention Services (May 2004).
[26] Gov. C. Section 11552 sets the annual salary for the Director of the Department of Health Services and thirty-three other executive positions. The salary began at $85,402 in January 1988, and the Government Code allows for increases comparable to but not exceeding the percentage of general salary increases provided for state employees during a fiscal year; and the immediate past director took a substantial pay cut to move from a local health department and serve as the Department of Health Services director.
[27] Association of State and Territorial Health Officials, "2002 Salary Survey of State and Territorial Health Officials" (Washington, D.C., 2002), Chart L.
[28] County of Stanislaus, "Job Classification and Salary report-As of 4/03/2004 ALPHA," http://www.co.stanislaus.ca.us/hr/SalaryInfo/per902.pdf (last visited May 18, 2004). Health officer salary is $5,028-7,543 biweekly, which equates to $130,728-196,118 annually; and Placer County, Health Officer, "2004 Basic Salary Schedule" County of Placer (A.O. 5:01 p.m. 12/26/03). http://www.placer.ca.gov/personnel/. htm (last visited on May 18, 2004). Health officer salary range 69 is $12,928-15,713, which equates to $155,136-188,556 per year; longevity pay is $16,499 per month and $197,988 per year; and City and County of San Francisco, Department of Human Resources, "Compensation Manual Fiscal year 2003-2004," April 12, 2004, http://www.sfgov.org/ (last visited May 18, 2004). The Health Director salary is $6,320-8,312 biweekly (1/3/04 rate), which equates to $164,320-216,112 per year.
[29] Institute of Medicine, "The Future of the Public's Health in the 21st Century," November 2002, p. 3. (report brief).
[30] California State Personnel Board, http://spb.ca.gov/employment (last visited May 12, 2004); and Department of Finance, "2004-2005 Salaries and Wages Supplement." The Fiscal Year 2004-2005 annual salary for the Department of Mental Health, assistant director of clinical services is $168,660.