GUEST POST by Lisa Junker, CAE, Director of Communications at the Association of State and Territorial Health Officials (ASTHO).

The United States is facing a “perfect storm of vulnerability,” said U.S. Centers for Disease Control and Prevention (CDC) Director Tom Frieden, MD, MPH, yesterday at the 2013 Annual Meeting of the Association of State and Territorial Health Officials (ASTHO)—and state and local public health officials are on the front line of defense.

Frieden began his remarks by encouraging his listeners to “go back to first principles” and keep in mind the first priority of government, which is to keep people safe.

“If the government can’t keep people safe, whether it’s the police or us in public health, we are failing at our number-one responsibility to the public,” Frieden said.

And to keep the U.S. population safe today, public health officials have to keep their eyes open for threats arriving from outside our borders. Infectious diseases, drug resistance, new pathogens, intentional engineering of microbes, and globalization of travel, food and medicines: “If there’s a blind spot anywhere, we’re at risk everywhere,” Frieden emphasized.

He also focused on CDC’s partnership with state and local public health, even during the current tight fiscal atmosphere.

“Overall, our approach has been to double down on support for the front lines [state and local health agencies],” he said. “We all are in this together…We have lots of problems and lots of opportunities, and the more effectively we are connected, the more effectively we can address these opportunities.”

A review of a recent economic surveillance survey by the National Association of County and City Health Officials (NACCHO) finds that despite modest improvement, local health departments in the United States are still struggling to recover from the recent recession. NACCHO administered the survey as part of the National Profile of Local Health Departments in 2012, prior to the 2013 sequester cuts.

Just under 80 percent of the 2,700 local health departments in the country responded to the survey, which included questions about budgets, staffing and program cuts. Close to half of the health departments responding to the survey reported reductions in, or elimination of, services in at least one health department program area for last year, and 27 percent reported budget cuts. Analysis of the survey results also found that local health departments lost 43,900 jobs through layoffs or attrition since 2008. While positions remained stable last year, many local health departments have been unable to fill positions that were cut in previous years.

The survey also found that certain program areas have been especially hard hit by budget cuts, including immunization (22 percent of local health departments faced cuts ); emergency preparedness (15 percent); and maternal and child health (15 percent).

“While workforce reductions and program cuts may have slowed in some areas of the country in 2012, on the whole, the budgets of our nation’s local health departments are not keeping pace with the general recovery,” said NACCHO Executive Director Robert M. Pestronk. “In fact,” added Pestronk, who previously served as the director of Genesee County health department in Michigan, “continuing annual draconian cuts associated with sequestration will further erode local health departments’ capacity to serve and respond. If keeping people healthy and safe is a priority, then we should rebuild local response capacity and health security, not keep cutting it.”

Examples of the impact budget cuts have had on health departments include:

• The Boston Public Health Commission (BPHC) was forced to limit its support of prenatal care services due to a five percent cut in federal funds for the Healthy Start Initiative. Other cuts resulted in the Health Commission losing community health worker positions that provided home visits to young families; case management for children and teens at risk of truancy; and services at school-based health centers.
• Because of statewide budget cuts to local health departments in Maryland in 2009, the state’s Frederick County Health Department eliminated a third of its nursing positions. Before those cuts that health department held three flu clinics simultaneously, but now supports one clinic at a time, which has reduced the number of residents getting vaccines and keeps the department from achieving its public health emergency preparedness goals.

NACCHO’s economic survey and analyses is supported by the Centers for Disease Control and Prevention and by the Robert Wood Johnson Foundation.

>>Read NACCHO's release on the new survey.

The Affordable Care Act (ACA), which kicks into high gear in January, was front and center at the recent annual meeting of the National Association of County and City Health Officials (NACCHO) in Dallas. U.S. Centers for Disease Control and Prevention Director Tom Frieden, MD, MPH, addressed the benefits to population health of many of the new law’s provisions and Kathleen Sebelius, Secretary of the Department of Health and Human Resources, which has overall responsibility for the law, spoke about the ACA via video.

For the most part, the role of local health departments under the ACA is still emerging and will become better known as more provisions are implemented and clarified.

To better understand what we know about that role and what will become better known down the road, NewPublicHealth spoke with Michelle Chuk Zamperetti, MPH, Senior Advisor and Chief of Public Health Infrastructure and Systems for NACCHO.

NewPublicHealth: Are there specific provisions under the ACA that apply to local health departments?

Michelle Zamperetti: There are no provisions specifically designated for local health departments but there are many provisions that impact local and state health departments. For example, many will be involved in the outreach and enrollment efforts for the new marketplaces and some will be designated as navigators to help people enroll for health insurance coverage in both the state-run marketplaces and the federally funded exchanges. For example, I recently learned that authorities managing a state-based health insurance exchange were not pleased with some of the navigator program applicants, so they reached out to a local public health director and asked that health department to be the navigator program leader in their region. And even in communities where health departments don’t give direct enrollment assistance—such as filling out paperwork online—we are confident that people with established relationships with their health department may use it as an entry point for finding out about health insurance, and health departments will need to know how to help them enter the system.

In addition to the insurance expansion provisions of the law, there are also important provisions to strengthen the coverage provided through insurance, particularly in the area of clinical preventive services. For health departments that provide direct services, there are opportunities to become in-network providers under the ACA.

NPH: Do you think many health departments will work together with non-profit hospitals, which now have a mandate from the Internal Revenue Service (IRS) to provide some form of community benefit in order to maintain their tax-exempt, not-for-profit status under the ACA?

Up to 80 percent of family physicians are expected to use electronic health records (EHRs) by the end of this year, and experts across the country are talking about ways to leverage this influx of data to inform better health. A pre-conference workshop at the National Association of County and City Health Officials (NACCHO) Annual Meeting focused on Beacon Communities, which are part of a pilot to demonstrate how meaningful use of EHRs can lead to better health and better health care at a lower cost. The HHS Office of the National Coordinator for Health IT is providing $250 million over three years to 17 selected communities throughout the United States where numerous institutions are sharing data to inform quality improvement and other data-informed efforts.

The NACCHO meeting highlighted Beacon communities that are partnering with public health in different ways to forge data-informed population health activities.

Health departments in North Carolina have been required to do community assessments since 2002 as part of a statewide health department accreditation program and are very experienced with working with this data, whereas hospitals are just now beginning to be required to do similar assessments under the affordable care act, according to John Graham, PhD, PMP, Senior Investigator for the NC Institute for Public Health at the Gillings School for Global Public Health, which plays an integral role in the Southern Piedmont Beacon Community.

“Health assessment planning and communication are tools that can be leveraged to foster more collaboration,” said Graham. “We really try to coordinate public health prevention and health care. We can do a lot with clinical interventions, looking at it from a population health perspective.”

Zachary Thompson, director of Dallas County Department of Health and Human Services, greeted the 1,000-plus attendees at last week’s annual conference of the National Association of County and City Health Officials (NACCHO) and expressed how honored he was to meet so many local health department leaders from across the country.

NewPublicHealth spoke with Thompson about Dallas’ particular health challenges and innovations the department has developed to help improve health in the community.

>>Read more NewPublicHealth coverage of the NACCHO Annual Meeting.

NewPublicHealth: Dallas ranks 67 out of 232 Texas counties in the County Health Rankings. What efforts are underway to help improve population health in the county?

Zachary Thompson: Dallas County is looking at various things, including adding more bike lanes and more parks where people can exercise. There’s a health assessment going on now to look at how all of the major stakeholders can come together to improve our health rankings. We have a great public health improvement work group that is working on ways to improve overall health in Dallas County.

NPH: West Nile virus was a major issue in Dallas last year. What are you doing this year to help keep the city safe?

Thompson: We had no deaths from West Nile virus in 2010 and 2011, then 20 deaths in 2012, which may have been a once-in-fifty-years event. Last year’s outbreak got everyone’s attention that West Nile virus is endemic in our community, and so we took the lessons learned and increased our resources.

We know what we improved on. We began to do year-round mosquito testing in 25 municipalities, and began meeting regularly with all the municipalities to assess their needs. Everyone has been on board with the overall integrated mosquito plan. So far this year we’ve had no human cases of West Nile virus. We definitely focused on preventive education—we started that earlier. We’ve also added additional ground-based truck spraying capabilities in the event that we needed to increase our spraying activity if we have a similar outbreak as last year. We have made insect repellent available for all senior citizens. Hopefully last year’s outbreak will have been a rare occurrence, but we’re prepared in any case.

Public health superstars as well as local health departments took home trophies from Dallas last week after receiving awards at the annual conference of the National Association of County and City Health Officials (NACCHO).

Mary Selecky

The most cheered awardee was Mary Selecky, the former health secretary of Washington State who retired earlier this year after 34 years in leadership positions at the state and local health departments. Selecky accepted her award brandishing a condom and a small bottle of hand sanitizer—symbols of her tenure. And when Carol Moehrle, district director of Public Health-Idaho North Central District in Lewiston and a former NACCHO president, who helped present the award, asked conference attendees who had been mentored by Selecky to step toward the front of the room, the space in front of the podium filled quickly. Selecky received the Mo Mullet Lifetime of Service award, named for a former executive director of NACCHO who also attended this year’s conference.

Read a recent NewPublicHealth interview with Mary Selecky, reflecting on her years of service in public health.

Local Health Departments of the Year

This year NACCHO also awarded first time prizes to local health departments, with awards given to applicants who showed creativity; innovation; sufficient evidence of outcomes and impact on the community; and collaboration with partners, community members and key stakeholders.

Small Local Health Department Winner: Crook County Public Health Department in Crook County, Oregon with a population of 10,000

Among its many innovations, the department worked with community partners to sponsor a school-based health center run by the local Federally Qualified Health Center and is very engaged in the implementation of the Affordable Care Act.

Medium Local Health Department Winner: Gaston County Health Department, Gaston County, North Carolina

The health department serves a little more than 200,000 residents and is working on ways to use data and data analysis to help improve health and reduce disparities. It also recently merged services with the Gaston County Department of Social Services. Prior to the merger, the health department analyzed the data needs of that agency and explored how it could use mapping to help jointly deliver services more efficiently and effectively. The health department is also training data-focused personnel and creating an informatics division, so the departments can further target outreach and intervention initiatives, and was an early adopter of electronic health records.

The Center for Disease Control and Prevention’s social media tool kit, CDCHealthCommWorks, was the focus of a standing room only session on the last day of annual meeting of the National Association of County and City Heath Officials (NACCHO). HealthCommWorks was developed through collaboration between the CDC’s Division of Cancer Prevention and the Oak Ridge Institute for Science and Education, in Oak Ridge, Tenn. Matthew Schnupp, MSPH, RN, a health education specialist at Oak Ridge, took the session attendees through SocialMediaWorks, one of the tools on the CDC site, to help optimize its use. The tool uses an algorithm to analyze which social media tools fit a particular campaign or public health issue based on time available to communicate messages, resources, population and goals.

“Social media plays a vital role in public health and is a strong tool for advocacy, communication, and education,” said Alisa Blum director of media and public relations at NACCHO. “Many local health departments use social media creatively to engage their communities and it has proven to be an important resource for public health preparedness and local health department response to disease outbreaks, emergencies, and other disasters.”

NACCHO also recently shared examples of successful public health social media campaigns:

The final plenary session at this year’s NACCHO Annual included a talk by Christopher Murray, MD, DPhil, director of the Institute for Health Metrics and Evaluation at the University of Washington on how data is used to measure health, evaluate interventions and find ways to maximize health system impact. Dr. Murray was a lead author on three pivotal studies published last week that used data to assess the state of health in the United States compared with 34 other countries and county level data on diet and exercise. One of the key findings is that Americans are living longer, but not necessarily better—half of healthy life years are now lost to disability instead of mortality; and dietary risks are the leading cause of U.S. disease burden.

NewPublicHealth spoke with Dr. Murray about the study findings, their impact and upcoming research that can add to the data public health needs to improve the health of all Americans.

NewPublicHealth: Tell us about the three studies that were published this week using the Institute’s research.  

Dr. Murray: The study in JAMA [Journal of the American Medical Association] is an analysis of a comprehensive look at the health of the United States in comparison to the 34 OECD [Organisation for Economic Co-operation and Development] countries. The study looks at both causes of death and premature mortality through over 290 different diseases and puts them all together in a comprehensive analysis of what the contributors are to lost healthy life. That study also looks at the contribution to patterns of health in the U.S., from major environmental, behavioral, and metabolic risk factors. In each of those categories, there are important findings:

• The U.S. spends the most on healthcare but has pretty mediocre outcomes and ranks about 27th for life expectancy among its peer countries.
• For many large, important causes of premature death, the U.S. does pretty poorly. And we also see a big shift towards more and more individuals having major disability—from mental disorders, substance abuse, and bone and joint disease.
• On the risk factor front, the big surprise is that diet is the leading risk factor in the U.S. It is bigger than tobacco, which is second and then followed by obesity, high blood pressure, high blood sugar, and physical inactivity. Diet in this study is made up of 14 subcomponents, each analyzed separately and then put together.

While immunizations are a ubiquitous symbol of public health, in the last decade or so many public health departments have shied away from using the icon on their home pages or even adding it to a top ten list of what they do in the hopes of making both citizens and policymakers realize that public health extends far beyond infectious disease. Yet as public health departments integrate their work with the private sector, who will do the vaccinating, how immunization records will be kept and who gets paid for the work are pivotal issues that local health officials are grappling with.

A well-attended session at the NACCHO Annual conference yesterday provided a few more questions than answers, but armed attendees with new information as implementation of the Affordable Care Act (ACA) begins and both public health and private providers see their roles change and merge. Significantly, the ACA is expected to enroll millions of children, and under new rules the Vaccines for Children program will no longer cover the cost for vaccines for children who can receive immunizations under their own insurance. That will reduce funding for some health departments.

Other changes ahead for vaccination coordination include the role of accountable care organizations (ACOs) in coordinating care under the ACA, electronic registries and billing for public health services, said Paul Etkind, MPH, DrPH, head of infectious diseases at NACCHO.

“Much of this has yet to play out, so there are many unknowns,” said Etkind, who added that vaccines are a good example of the need for up front conversations with providers about what public health has to offer and a good way for health departments to become part of ACOs. “Going forward there will be a greater emphasis on coordinating care between the public and private sectors, than in delivering the care in many cases and public health needs to be active players in this process.”

With just 83 days to go until health insurance marketplaces open up to allow otherwise uninsured Americans to sign up for health coverage under the Affordable Care Act (ACA), NACCHO Annual has a good number of plenary and other sessions focused on the role of public health in implementing the law. 

>>Read more NewPublicHealth coverage of NACCHO Annual.

In his address to the 1,000 plus attendees at this year’s NACCHO conference, Centers for Disease Control and Prevention Director Tom Frieden, MD, MPH, talked about what local health departments can do to support ACA. “This is an all hands on deck situation,” said Frieden. “We want to do a lot with improving quality of care, but first we’ve got to get people signed up.”

Frieden ticked off actions that local health departments can take to help support enrollment, including:

• Provide resources to the community on getting insured & the benefits of being insured, including free preventive care.
• Educate every resident served by the department, such as immunization, tuberculosis and STD clinic patients, on how they can enroll.
• Educate every organization that the health departments connects with, such as schools, courts and businesses, on how stakeholders can enroll.