Faces of Public Health: Napa County's Karen Smith on Budget Cuts at Local Health Departments

Oct 30, 2013, 11:49 AM

Karen Smith, MD, MPH, Health Officer and Deputy Director for Public Health at Napa County Health and Human Services Karen Smith, MD, MPH, Health Officer and Deputy Director for Public Health at Napa County Health and Human Services

Since 2008, local health departments have cut nearly 44,000 jobs, according to a recent survey conducted by the National Association of County and City Health Officials. Although workforce losses and gains were roughly equal in 2012, 41 percent of local health departments nationwide experienced some type of reduction in workforce capacity and 48 percent of all local health departments reduced or eliminated services in at least one program area. Currently, local health departments reporting cuts still exceed the percentage of local health departments reporting budget increases.

California’s Napa County has dealt with its budget cuts by revamping its health department in order to continue to stay on mission.

“I think we've come out the other end of all this as a much stronger health department,” said Karen Smith, MD, MPH, Health Officer and Deputy Director for Public Health at Napa County Health and Human Services. “We moved from what I think of as an ‘old style’ [public health agency] to a department that focuses on our role as a convener/partner, providing expertise and leadership, and helping to craft policy.”

NewPublicHealth recently spoke with Smith about the methods Napa Public Health used—and that other departments might follow—to adapt and improve in the face of budget cuts.

NewPublicHealth: How have budget changes impacted your department over the last five to ten years?

Karen Smith: Napa Public Health started out with a lean health division for the size of the county compared to some of our colleagues, and we remain lean. We have not really decreased services, however. We were able to get out ahead when we saw looming budget constraints.

Napa Public Health is part of the County’s Health and Human Service Agency, which includes social services, as well as mental health, drug and alcohol, child welfare services, comprehensive services for older adults and public health, and our administrative divisions. The previous director had a distinctive approach to budgeting: that the agency has a bottom-line budget and within that we have very detailed division budgets. So I have excruciatingly detailed budgets for every single program within public health, and that was crucial to our being able to respond to the budget shortfalls in creative ways that had limited impact on services.

The director and our chief fiscal officer proactively assigned budget cut targets based on our best estimates of what was going to happen to the various funding streams. Divisions were assigned targets based on each division’s proportion of the Agency’s budget. After a collaborative decision making process between divisions, the local county money in the agency budget was reapportioned between divisions to fill gaps left by state and federal cuts. This was done with a focus on maintaining services to the public and avoiding layoffs. In this way Public Health—which originally had very little local money in our budget and which suffered major cuts to external funding—now has significantly more county funding maintaining our services.

In approaching the budget deficits, each division was tasked to figure out what we would cut if we had to meet the entire target we were given. This exercise was crucial. It allowed people who really understood the programs and the services to decide how to propose cuts. Each manager in public health had to come to the table with cuts. No one was exempt. Throughout the period of the recession we went through 12 rounds of budget proposals.

Early on, some administrative issues gave us more money. For example, the maximum contract for our medical director for the Children’s Medical Services programs was $95,000. The auditor used that number in our budget regardless of how much money was actually spent. We went back and said, “Look, we’ve never used more than $30,000 on this contract” and convinced the auditor that our budget could reflect $30,000 rather than the $95,000 contract maximum. By doing that kind of detailed budget analysis we actually withstood the first couple of rounds of budget projects. It was more like a budget correction than a budget cut. Money that would otherwise have been held in the line item for the medical director’s salary was freed up to be used elsewhere in the budget. In a normal year, those funds would simply have not been spent and swept back into the county’s general fund at the end of the fiscal year. Instead, the agency was able to use it during the fiscal year.

You have to be willing to stop doing things that aren’t essential, or can be done by someone else, that are costing you a great deal of money.

NPH: Can you give us an example?

Smith: We had a “Welcome Every Baby Program” that was largely funded by a grant from a philanthropic donor to send public health nurses to the homes of every baby born in Napa County who wanted it. We put in a lot of time administering the program, yet fewer and fewer people were being seen. Ultimately, a cost benefit analysis found we were seeing the high risk moms anyway and we made the very difficult decision to not apply again for the funding.

NPH: Is there still more you can consolidate if you were asked to?

Smith: Not without substantially impacting the core services we provide. We increased fees where we could, such as emergency medical services. But if I had to do this again, I would have to start cutting people because there isn’t a lot left to cut. Cutting more would be extremely damaging to services. We feel lucky that we managed to stay afloat with minimal losses and very lucky that the economy turned around when it did.

This commentary originally appeared on the RWJF New Public Health blog.