AGENDA REPORT
Meeting Date: September 12, 2022
Item Number:
To: Honorable Mayor and City Council
From: Cynthia Owens, Policy and Management Analyst
Subject: REQUEST BY MAYOR BOSSE TO CONTINUE THE DISCUSSION
ON THE FORMATION OF A LOCAL PUBLIC HEALTH DEPARTMENT
Attachment: 1. Possible Components of a Provisional Approval Application Process by CDPH
RECOMMENDATION
The City Council may also provide any direction it wishes on this item.
INTRODUCTION
This item is a request of Mayor Bosse to continue the discussion on the formation of a local public health department. At the request of Mayor Bosse, this report will provide an interim update to the City Council on staff’s progress in exploring the formation of a local public health department.
DISCUSSION
Background
On December 1, 2020, the City Council reviewed the closure of outdoor dining by the Los Angeles Health Officer due to the increase of COVID-19 cases in Los Angeles County. During the discussion, then Councilmember Bosse requested staff explore the possibility of creating a local public health department, which the City Council unanimously supported.
At the December 8, 2020 meeting, staff provided a broad overview of creating a local public health department. The City Council directed staff to continue to explore creating a local public health department and to bring their findings back to Council.
On April 12, 2022, staff provided an update to the City Council on the research that had been completed for creating a local public health department and what research needed to be completed in order to bring more information back to City Council.
F-1
Overview of the Requirements for Operating a Local Public Health Department The California Department of Public Health (“CDPH”) is responsible for:
Establishing, by regulation, standards of education and experience for professional and technical personnel employed in local health departments and The organization and operation of local health departments.
Section 1276 of Title 17 of the CCRs outlines the minimum requirements, responsibilities, and functions of a public health department. A summary of the twelve basic services, responsibilities and functions are as follows:
1. Collection, tabulation and analysis of public health statistics including population data, natality, mortality, and morbidity records as well as evaluation of service records.
2. Health education programs, including staff education, consultation, community organization, public information, and individual and group teaching, such programs to be planned and coordinated within the department and with schools, public and voluntary agencies, professional societies, and civic groups and individuals.
3. Communicable disease control services including availability of adequate isolation facilities, the control of the acute communicable diseases, and the control of tuberculosis and the venereal diseases
4. Medical, nursing, educational, and other services to promote maternal and child health
5. Environmental health and sanitation services for food; housing and institutions; radiological health; milk and dairy products; water oriented recreation; vector control; waste management; and air sanitation, among others
6. Public health laboratory services
7. Nutrition services, including appropriate activities in education and consultation for the promotion of positive health, the prevention of ill health, and the dietary control of disease
8. Chronic disease prevention or mitigation services
9. Services directed to the social factors affecting health
10. Occupational health promotion
11. Family planning services
12. Public health nursing services
Cities with Public Health Departments in California
Under California’s Health and Safety Code, the governing body of a county is required to take measures necessary to preserve and protect the public health in unincorporated areas. Cities, on the other hand, are statutorily required to take measures to preserve and protect public health in their city. While each city is required to appoint its own public health officer, cities are permitted to make arrangements for the county to exercise the same powers and duties within the city as are conferred upon the city health officers by law. Most cities in California have deferred their authority to the counties.
In California, there are only three cities which have their own full service local public health department: Berkeley, Pasadena, and Long Beach. Berkeley established its health department in 1880, Pasadena established its health department in 1892, and Long Beach established its health department in 1906. The City of Vernon only offers environmental health services and is not considered a local public health department by CDPH.
During the pandemic, several cities expressed an interest in exploring operating a local public health department, including Palmdale, Santa Clarita, West Covina, and Whittier.
Of these, West Covina is the furthest along in establishing their own local public health department.
In February 2021, the West Covina City Council adopted a resolution and an urgency ordinance to terminate the Health Officer Services provided by LA County Public Health.
In theory, this would have allowed West Covina to begin providing local public health services on July 1, 2021; however, they are still waiting for authorization by CDPH. As it has been over 100 years since a local public health department was created, CDPH is establishing guidelines for an application and approval process. Conversations are actively occurring between West Covina and CDPH to establish this process. City staff has also spoken with West Covina and will continue to have conversations with West Covina as they move through the process with CDPH.
Additionally, staff spoke with CDPH about the process for establishing a local public health department. CDPH stated they are currently only working with West Covina in California for establishing a local public health department. CDPH did advise they are creating an application and approval process, with some of the guidelines coming from the national guidance for becoming an accredited health agency. When asked how soon the application and approval process would be finalized, CDPH only advised it would soon. Attachment 1 provides a summary of the possible components of a provisional approval application process
Short Questions and Answers on Creating a Local Public Health Department The following questions and answers were part of the research staff conducted after the April 12, 2022, Study Session based on the existing CCR’s. These are a few of the key questions as to whether or not the City can form a local health department, whether the City would be eligible for state funding, and whether the City could contract out any of the twelve required services.
Question 1: Can a city with a population of less than 50,000 residents form an independent local health department?
Answer 1: Yes. No statute expressly prohibits a city with less than 50,000 residents from creating its own health department.
Question 2: Will a city with a population of less than 50,000 residents be eligible for state funding under the Health & Safety Code (“Code”)?
Answer 2: No. The Code expressly provides state funding for local health departments qualifying for assistance, and the definition of "local health department" includes a minimum population threshold of 50,000. However, the City could still apply for grants for funding; however, grant funding is never guaranteed.
Question 3: Can a local health department contract out any of the “basic services” required under Title 17 of the CCRs?
Answer 3: Yes, if contracting for public health services with the county, but unknown as to contracts with private entities.
Question 4: Can Beverly Hills issue its own health officer order if some of the 12 required tasks are contracted out?
Answer 4: Maybe. If the City contracts with LA County Public Health for some of the 12 required tasks, then the City loses its enforcement powers to the County. State law is ambiguous on whether the City can contract with private entities due to
Timeline to Establish Local Public Health Department
If the City desires to establish its own local health department, the City must first terminate the services provided by LA County Public Health Department. Pursuant to the California Health and Safety Code the services provided by LA County Public Health Department:
“…shall continue indefinitely until the governing body of the city terminates them by adoption of a resolution and ordinance and service of a certified copy on the clerk of the board of supervisors on or before the first day of March of any subsequent year. The services of the county health officer shall terminate on the first day of July following service of notice.”
Based on the express language of the statute, should the City Council decide to establish a local public health department then the City Council is required to adopt both a resolution and an ordinance terminating the LA County Public Health Department services, and serve a certified copy of the resolution and ordinance on the Clerk of the County Board of Supervisors no later than March 1, 2023. To fully terminate the LA County Public Health Department services, the City is required to provide notice of termination of the Health Services Agreement at least 30 days prior to the end of the fiscal year, or by May 31, 2023. If so, the termination should be effective July 1, 2023, though it may not be the case depending on the approval process by CDPH.
Potential Advantages and Disadvantages of Establishing a Local Public Health Department
The United States has 51 state health departments (Includes the District of Columbia) and thousands of local health agencies.
Depending on the state's structure, local agencies’ authority may flow through the state health department or be granted independently. Their size, structure, and authority differ, but all were created by a legislative grant and share the common goal of promoting and protecting health within their communities. Health departments traditionally work in concert with other agencies and nongovernmental organizations.
Approximately half of the state health agencies have a significant source of authority that allows them to enact rules and regulations to further their public health missions, and 73 percent of local health departments use this authority to adopt public health regulations.
This rule-making authority stems from laws passed to advance public health in specific ways.
Some advantages a local public health department may have are:
Ability to build programs tailored to the community and create targeted interventions
Focus on residents of highest need in the City without having to split resources among vulnerable populations across the Los Angeles County Beverly Hills having less than 50,000 residents. From the California Health and Safety Code, the City would be ineligible for state funding if the City contracts with a private entity, but the City is already ineligible for state funding due to the City’s population being under 50,000 residents. The question is whether the City can issue and enforce our own health officer order if the City contracts privately. To determine this, staff would need to consult with the CDPH. Staff is already in the process of obtaining this answer; however, the answer was not available at the time this report was published. It is unknown if staff will have an answer by September 12, 2022.
Authority to create their own budgets as well as establish taxes (subject to voter approval) and (subject to state law restrictions) fees for public health Some disadvantages may include:
Limited autonomy due to state-mandated compliance
o CDPH could determine any reopening and safety guidance for a public health emergency which would override a local public health officer order o CDPH could determine local public health departments must follow county public health officer orders
Delays in managing cross-jurisdictional disease investigations and inefficient use of resources for disease surveillance and emergency preparedness Potentially creating duplicative administration infrastructure and fragmented or redundant public health services
Loss of economy of scaling – A smaller health department is typically more expensive to run than one serving a larger city or entire county. Additionally, costs for the local health department are borne by the City with no transfer of funds from the Los Angeles County tax base back to the City Direction Requested by City Council
It has been determined that under state law, the City has the authority to establish a local public health department. Staff is approximately half way through completing the base research for creating a local public health department. Staff is still pursuing answers to several questions on creating a public health department such as:
1) While the City cannot contract with LA County Public Health for any of the 12 basic services and still enforce a City issued Health Officer Order, is CDPH willing to allow the City to contract with private entities for services such as public health laboratory services? While we know cities over 50,000 residents can do this, the state law is not clear if a city under 50,000 residents may be able to do so.
2) There has been some indication that some physicians and clinical nurses from the community and surrounding area may be willing to volunteer their time to help provide some of the 12 basic services. Staff is still working with CDPH to determine what sort of commitment would be required so CDPH would authorize the use of some volunteers in combination with paid staff to serve the needs of a local public health department.
3) Can the City phase in the establishment of a local public health department or does the entire department have to be stood up at the same time? Most likely the City would be unable to issue a health officer order until such a time all 12 basic services have been assumed by the City from the LA County Public Health.
4) Staff is talking with West Covina and CDPH as the final application and approval process by CDPH is nearing completion. What this may look like could influence what the formation of a local public health department will look like.
Staff will continue to have conversations with both CDPH and West Covina to answer these questions and any others that are not outlined in this report or that may arise as research continues into this topic.
Staff is seeking direction from the City Council on the following questions:
1) Does the City Council still support the pursuit of creating a local public health department and the development of a model for what a local public health department may look like for the City?
2) Does the City Council wish to consider having volunteers from the medical community work in the local public health department?
3) Does the City Council wish to use the City’s Community Charitable Foundation, which is a 501(c)(3), and for donations from the community for expenses related to establishing and operating the local public health department? 4) Does the City Council want staff to continue to explore the following models for a local public health department:
a. Full-service public local health department – all services provided by City b. Full-service public local health department – some services contracted with a private entity
c. Full-service public local health department – all services contracted with a private entity
d. Any other vision of the City Council for a local public health department? The option to contract some or all services with LA County Public Health has not been included as an option as the City would be unable to enforce any health order issued by a City Health Officer, making the City ultimately still subject to LA County Public Health’s Health Officer Orders.
The City Council may also provide any direction it wishes on this item.
FISCAL IMPACT
The cost to startup and provide an annual operating budget for a local public health department is unknown and highly dependent on the level and type of service the City Council wishes to provide including any supplemental services the City Council wishes to offer above the 12 basic services required by the state.
For some services, such as permitting and inspecting environmental health and sanitation services for food industries; housing and institutions; and radiological health, the City can develop a fee to recover the costs associated with this programming once a staffing model is developed. Therefore, it would be anticipated that once the known expenses are for this service that the City could recover nearly all costs through charging and collecting fees. There may be other local public health department services the City may be able to develop a fee for, but this will require more time to research and to develop a plan.
The City Council should not anticipate receiving any offsetting revenue for the 12 basic services from the state given the City is ineligible for the state funding as discussed above in the section titled Short Questions and Answers on Creating a Local Public Health Department.
The City indirectly pays Los Angeles County for public health services, as part of the City’s General Services Agreement; however, it is not clearly defined what those costs are. Therefore, there is no anticipated cost savings to operating a local public health department from this agreement that could be applied towards the City’s cost. This does not prevent the City from exploring this option, but at this time, it is difficult to say what amount, if any, the City could get back from the Los Angeles County. Staff would need more time to initiate conversations with the Los Angeles County should City Council decide to move forward with developing a public health department.
The City could also consider applying for non-profit, state, and federal grants for covering the costs for certain public health services. For example, the United States Department of Health Services offers grant opportunities to strengthen maternal and child health access across the nation as do numerous non-profit associations. Many health departments do receive funding above and beyond the state funding for local health department from grant opportunities.
Another consideration for the City Council is that the community may wish to donate money and/or expertise for establishing a local public health department. The residents of Beverly Hills may be willing to provide substantial donations for funding the startup costs and ongoing annual costs for a local public health department. Staff has identified that these funds could come through the City’s Charitable Solicitation Foundation, which is a 501(c)(3), and be designated specifically for the local public health department.
Nancy Hunt Coffey
Assistant City Manager
Approved By
Attachment 1
CITY OF BEVELRY HILLS
POLICY & MANAEMENT DEPARTMENT
Possible Components of a Provisional Approval Application Process by CDPH
In December 2021, the California Department of Public Health (“CDPH”) met to discuss what a new local public health department application and regulation process would consist of, given it had been almost 100 years since the last establishment of a local public health department before West Covina submitted a request to CDPH to establish their own local public health department. Some of the guiding principles discussed in December included:
1) The new local public health department must meet public health statutory and regulatory requirements in order to receive funding;
2) The applicant must demonstrate a clear understanding of community health needs; and 3) The applicant must prove ability to address community health needs through the provision of high quality public health services.
CDPH is still considering the possible components of a provisional approval for establishing a new local health department. This currently consists of:
1) Proof that baseline requirements are met
2) Submittal of a letter of intent which describes rationale and need for forming a new local public health department
3) Feasibility study
4) Timeline, budget, and staffing information for service provision 5) An agreement or memorandum of understanding with the county / other organization for services or staff that will be contracted out if any services are proposed to be contracted out
6) Community Health Assessment and Community Health Improvement Plan and possibly other requirements
7) Site visit
Additionally, the proposal includes that within a year of being approved, the local public health department will need to provide CDPH with an update of services and program provisions as well as staff hiring. Also, within one year of full approval, the local public health department must provide all remaining public health services which are not provided by the county.
In order for CDPH to review and make a determination of a new local public health department application, and enforce the application process, CDPH needs to have regulatory authority granted to it by the California Code of Regulations (“CCR”). Per CDPH, no such regulations currently exist; therefore, an amendment to the CCR needs to occur in order to grant CDPH the authority it needs.
Pursuant to a recent conversation with CDPH, they are currently working on revising the CCR’s to include an update to language that is outdated as well as a process for receiving and reviewing applications for establishing a new local public health department. The CDPH representative advised they still need a few months to finalize their proposed revisions to the CCR’s before they will release the proposed regulations for public comment.
Until this occurs, should the City decide to move forward with a local public health department, then the City Council should be aware that the approval process may be delayed until the CCR can be amended and the application process finalized.
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Additionally, City staff met with the staff from West Covina for an initial discussion on what steps they have undertaken to establish their local public health department. West Covina is working closely with CDPH to develop an application process. Once completed, West Covina will have five to ten days to provide public comment on the application process. Preliminary thoughts on what this process may look like include nine steps outlined below. Again, this is preliminary and is not necessarily what the final application process would look like.
Potential steps for establishing a public health department which CPDH may implement:
1) Local governing body resolution
2) Notification to the applicable county health department and CPDH 3) Acknowledgement by CDPH which may include:
a. Acknowledge receipt of the city’s intent letter
b. Designate a CDPH contact person or other staff as necessary to coordinate with the city to conduct an initial conference with the city, applicable county health department and designated CDPH staff
c. Establish a schedule for consideration of the City’s application 4) Preliminary application to include:
a. Copies of authorizing resolutions
b. Overall description of the process
c. Description of approach for delivering state mandated and other public health services
d. Implementation schedule
5) Review and approval of preliminary application by CDPH 6) Approval of preliminary application
7) Initial implementation
8) Final application
9) Final approval