For the first time in more than 30 years, the state of California has an official department dedicated to promoting public health. The shift occurred on July 1, when the state’s Department of Health Services was split into two separate entities — one focusing on population-based efforts to prevent illness and injury and the other on providing medical services.
The organizational restructuring was mandated by legislation passed last year and signed by Gov. Arnold Schwarzenegger (R). The newly created Department of Public Health will absorb such key areas as disease surveillance, environmental health, health promotion, prevention of chronic diseases and infectious disease control activities. The Department of Health Care Services will administer Medi-Cal and other programs designed to deliver clinical care to individuals and families.
Health experts, government officials and others had debated such a change for years. The effort gained impetus after the terrorist attacks of Sept. 11, 2001, which exposed the need for improved emergency response capabilities. So did successive waves of emerging infectious diseases in recent years, with West Nile Virus and SARS the two most prominent. Growing epidemics of conditions like obesity and chronic ailments such as diabetes further highlighted the need for more aggressive community- and population-based efforts.
Many public health advocates fought for the change and expressed enthusiasm for the possibilities of the new organizational structure.
“Having a separate division that can really focus on what’s needed by the community to keep people healthy is an incredibly important opportunity,” said Larry Cohen, executive director of the Prevention Institute, an Oakland group that promotes community-based primary prevention activities. “And it provides a platform to raise some really important issues — the fact that it’s a separate division makes it clear that public health is not just about medical care after the fact.”
The change comes four years after the Little Hoover Commission, an independent state oversight agency, starkly declared in a widely read report that “the state’s public health leadership and organizational structure is ill-prepared to fulfill the primary obligation of reducing injury and death from threats that individuals cannot control, such as environmental hazards, bioterrorism and emerging infectious diseases.” The report found that core public health functions were scattered throughout the executive branch and recommended the creation of a separate public health department to manage and coordinate such activities.
The California Conference of Local Health Officers, an organization with a direct line to the state public health officer in the new department’s structure, helped to develop the legislation, which was carried by former Sen. Deborah Ortiz (D-Sacramento). The legislation transferred to the new entity the offices responsible for prevention services, licensing and certification, health information and strategic planning, and public health emergency preparedness, among others.
“In California, we face earthquakes, forest fires, as well as threats of terrorism and disease outbreaks, like pandemic flu,” Gov. Schwarzenegger stated last year when he signed the legislation mandating the change. “This new Department of Public Health is another way we are strengthening our state’s emergency preparedness and taking action to make the state safer.”
To broaden the legislation’s appeal, the sponsors agreed that it would be “budget neutral” in its initial implementation phase. In an early version of the bill, the public health officer was envisioned as a Cabinet-level position reporting directly to the governor, although the final bill left both of the new departments under the state’s Health and Human Services Agency, said Dr. Anthony Iton, the Alameda County health officer, who testified in support of the legislation.
Dr. Iton said that he hoped the change, by raising the visibility of public health, would reduce the degree to which politics drives policy. “The extent to which public health is buried in another agency makes it easier to politicize the issue,” he said. “The question is obviously how free the public health director will be to speak up and prioritize issues that he thinks are important.”
Moreover, Dr. Iton said the change must be followed up with sufficient funding to rebuild capacity and develop the infrastructure necessary for a sustained effort to protect and enhance the public’s health. He pointed to a significant “brain drain” from the state health agencies to both the counties and the private sector, where physicians, lab technicians and others can earn significantly more.
“There has been a long underinvestment and even disinvestment of public health in California, and it would be reckless to ignore that,” Dr. Iton said.
The reorganization has caused little apparent dislocation, thus far. About 400 employees out of the approximately 6,000 in the former Department of Health Services are being relocated to different offices this summer. The rest will remain where they are and most functions, including those involving interactions with the public, will be performed by the same agency or office as before.
“So far, the biggest change has been in my e-mail address,” said an employee whose unit is now part of the new public health department.
The mandate of the new Department of Health Care Services is to finance and manage Medi-Cal and other health care programs that deliver services, especially to low-income individuals and families, and others who meet specific criteria.
The last head of the erstwhile Department of Health Services, Sandra Shewry, has been named to head the new agency. The proposed DHCS budget for 2007-2008, which includes the cost of medical care for those covered under its programs, is $38 billion, compared to only $3 billion for the public health department.
The first director of the new public health department is Dr. Mark Horton, a former health officer for Orange County. He said he was still in the process of installing a top management team and already was beginning to look beyond the year of budget neutrality to determine the department’s future financial needs.
Dr. Horton asked that the new department not be judged solely on the basis of current funding levels. “It’s short-sighted to equate progress with additional resources, to say you’re not doing anything because it’s budget-neutral,” he said.
Dr. Horton noted that the department has launched a comprehensive strategic review to sharpen and clarify its mission and goals, assess the major public health threats and challenges facing the state and determine what the new department requires to carry out its responsibilities, with a particular emphasis on maintaining adequate laboratory capacity.
Another of Dr. Horton’s goals for the agency is strengthening existing partnerships with other state and local agencies, academic and health care institutions, professional associations and other public health advocates.
Dr. Richard Jackson, for one, is pleased with the organizational changes, although he seconded Dr. Iton’s call for significant new investment in public health. Dr. Jackson, a former head of environmental health at CDC, became California’s public health officer within the former Department of Health Services in 2004 but quit the following year.
Dr. Jackson’s departure dismayed local public health officials around the state, many of whom viewed it as a blow to expanding public health resources and improving the state’s ability to cope with crises and emerging threats.
Dr. Jackson, who now is a professor of environmental health and health policy at UC-Berkeley, said that at the time, he was frustrated because the public health officer’s position lacked authority and adequate support from the administration, hampering his ability to take actions he deemed necessary.
He said the enormous budgetary and administrative infrastructure established to support and manage Medi-Cal and other health care delivery service programs dwarfed the resources at his disposal for key public health functions.
“The structure of this big insurance company I was working for was totally ill-suited for both the high-intensity science and high-intensity urgency that needed to be brought to bear,” Dr. Jackson said. “It became clear to me after about a year that we needed to reestablish an independent agency that’s really dealing with issues of this importance. I remember saying that they wouldn’t put the CDC under the Medicaid office in Washington.”
Not all public health advocates have been enthusiastic about the new department; some see it largely as a cosmetic shift that by itself won’t necessarily have much impact.
“I don’t see that making an organizational change and declaring that there’s a department of public health will improve public health,” Dr. Wendel Brunner, the director of public health for Contra Costa County, said. “The question is, ‘What are you doing that’s different than what you were doing before, and why should we respect you more?'”
Dr. Brunner added that the majority of county health officers around the state do not share his perspective but that he also is not “a lone wolf” on the issue. “My concern is that now that we have a separate department of public health, it will breed complacency and foster the illusion that we’ve actually done something,” he said. “On the other hand, if it really does mobilize local and state enthusiasm for promoting public health, maybe it will lead to something being done.”