“Been down so long, it looks like up to me.” —Furry Lewis

If local public health officials in Kansas had the time or money (which they don’t) to go shopping for a theme song, the classic Furry Lewis blues lyrics probably would fit the bill better than, say, “Good Day Sunshine,” by the Beatles.

Funding for local health departments has been flat or declining for as long as people in the business seem to remember. What some in government call lean times, local health workers in Kansas and across the nation have long called normal.

“I only have one nurse in each county anyway,” said Diane Bertone, administrator for the Southeast Kansas Multi-County Health Department. “So I can't very well lose too much more. The nurses in each of my four offices do it all and have for a number of years. Tough times? That’s normal.”

In addition to handling administrative chores, Bertone is a nurse practitioner. In 1972, her agency became one of the first in Kansas to adopt a multicounty or regional organization model. It covers Allen, Anderson, Bourbon and Woodson counties with an annual budget of $600,000, which will be cut 5 percent in 2012, she said, because of shrinking property tax revenues in Bourbon County.

There also is a regional health agency in sparsely populated northwest Kansas, but most Kansas counties — at least for now — maintain their public health department. And local government continues to be the primary funding source for public health services in the state.

29,000 jobs cut
Local health departments depend on a mix of federal, state and local dollars. In Kansas, officials say, about 64 percent of the money comes from local government, 26 percent from federal grants or aid, and 10 percent from the state. All three sources have been dwindling. The funding started shrinking at an accelerated pace in 2008 as the economy went into recession and government budgets suffered accordingly.

Since 2008, 29,000 public health jobs were eliminated nationwide as a result of funding cuts, according to a report by the National Association of County and City Health Officials (NACCHO). That was about a 19 percent reduction overall.

According to NAACHO’s state-by-state survey, 30 percent of Kansas local health departments shed workers between July 2009 and June 2010.

“In the last couple of years there have been (funding) reductions, and we have done our best to absorb the cuts” so that they weren’t fully passed on to local agencies," said Jane Shirley, director of local health at the Bureau of Community Health Systems at the Kansas Department of Health and Environment. “But most of their funding comes from local government, and that also is a deteriorating picture.

“We do know that health departments across the state — from the littlest to the biggest — are reducing budgets and staffing,” Shirley said. “When you’re talking about an agency that has multiple staff, that can mean one person taking on two jobs or three jobs. Unfortunately, in rural areas this can have huge impact because they have very limited staff and resources. So now we’re seeing offices reducing hours and the services they can provide. And that can put additional stress on the system, because in those cases citizens may turn to the department in a neighboring county, which puts a strain on them.”

Not a pretty picture
The consequences are varied: fewer jobs in the community, fewer services, and often new or increased fees for essential and basic health services for which many Kansans have trouble paying.

“It’s not a pretty picture,” Shirley said.

And there seems to be no end in sight to the problem of shrinking resources.

“The depth and impact of budget cuts varies from county to county, and thus from health department to health department,” said Michelle Ponce, executive director of the Kansas Association of Local Health Departments. “But I think we all feel some level of anxiety about continuing to provide a high level of service to our communities, while not knowing what type of further reductions may be imposed.”

Public health officials, as much or more as anyone in U.S. health care, focus on preventing illness. And most health experts agree prevention is something that needs more attention, not less, if the nation’s health care costs are to be contained.

For now, preventive care represents a small percentage of total health spending.

“We need to maintain an investment in public health or else we'll never get a handle on our health care costs,” said Laura Hanen, chief of government relations and public affairs for NACCHO in Washington, D.C. “The status quo is cut, cut, cut.”

Affordable Care Act
Hanen said one of the few bright spots on the horizon for public health funding was a provision of the controversial Affordable Care Act that over the next 10 years would pump about $11 billion into prevention and public health programs.

“This was a mandatory spending pot to beef up workforce and capacity that would be transformative to communities,” Hanen said.

But those dollars still remain tenuous given the political opposition to the health reform law and new efforts in Congress to cut the federal deficit.

As part of the recent deal to extend the federal debt limit, the 12-person Joint Select Committee on Deficit Reduction was created and tasked with cutting $1.5 trillion over the next 10 years. The panel, which has six members from each party and each chamber of Congress, is commonly called the “supercommittee.”

The new funding “is very vulnerable in the supercommittee because it’s part of the Affordable Care Act, and there are those on the supercommittee who do not support the fund and have never supported the fund,” Hanen said. “We know it will be in the mix (of programs considered for cutting). There are over 700 organizations that support the (prevention) fund, and they're working very hard to educate members of Congress about the importance of the fund. But it is very vulnerable.”

Meanwhile, and apart from the ACA funding, Hansen said her organization anticipates more cuts in federal public health spending again in 2012.

“The entire CDC (Centers for Disease Control and Prevention) budget was cut. CDC gets their funding from Congress, and they send a lot of their funding to state and local health departments. The more pain CDC is in, the more they have to pass that on to their grantees. I wish I could say there is a bright spot. We’re very concerned about fiscal 2012.”

Pay now or pay later
Hanen said surveys show there is general support in Congress and in the public for prevention programs.

“It’s just that when you’re looking at a deficit as large as we are in this country, people want immediate savings now and they’re not thinking about savings in the future. The problem is, the more you cut your investment in prevention, the more you will pay later.”

Hanen said the erosion of core functions due to lack of funding at public health departments across the nation is a matter of paramount concern to her group and others.

“Kansas is in no way alone,” she said. “The decimation of local health departments is the number one issue in public health.”

Taking up the slack
Pam Rickard, interim director of the health department in Barber County, knows that firsthand. She and the handful of other workers in the agency have seen a string of directors come and go in the past 15 years.

The departure of the last director actually helped stabilize the department’s budget this year, though Rickard is now doing much of her old job in addition to the director’s.

“I keep thinking I'm missing something big somewhere,” she said. “But it hasn't reached out and slapped me yet. It seems like everybody kind of picks up the slack. I haven't had to work too many longer days than I did before.

“Right now, without the administrator, our budget looks pretty good,” she said. “But if they put another whole person back in here like before, things will be pretty tight.”

Rickard took a long pause when asked what her agency would do with an extra $500,000, as if the notion were too far-fetched even to imagine.

“That would be a lot of money,” she said. “There are services out there that people do ask for. Transportation is kind of a hard thing for people because we live out here where it is hard for people to get to doctor appointments. But churches and other people will help volunteer for that. We don't have a dentist in Barber County, so we have to travel at least 30 miles, and that's hard for people who don't have the funds or a car to drive.”

Accreditation costs
Midge Ransom, director of the Franklin County Health Department, said the agency’s federal funding would be decreasing between 5 and 10 percent, which would mean less money for maternal and child health programs and for family planning.

If the county doesn’t help make up the difference, she expects the agency will need to collect more fees.

"Without increasing our county mill levy, I see more dependence on fee-for-service income in 2012," she said.

Her department’s annual budget is about $800,000, which is more than that of many rural counties.

"There's never enough money to do everything you want to do,” she said. “There are certainly gaps. We are fortunate here to be sufficiently funded to maintain what we're doing."

She said one major gap was community education, especially regarding obesity.
Tight funding also might affect the work her department has been doing for more than three years to be accredited as part of a major national and statewide initiative to introduce consistent standards for local health departments.

A requirement for accreditation is doing a Community Health Assessment and Community Health Improvement Plan.

Her department is involved in a regional NACCHO grant to help it gain accreditation.
But the initial application fee is $14,000 with a total cost of $50,000 over five years.
Ransom said her current budget would preclude the county from applying now. She said only one of the eight counties participating in the regional grant — Greenwood — could afford the application fee. The other regional counties that can’t afford it are Lyon, Osage, Morris, Chase, Coffey and Wabaunsee.


— Phil Cauthon contributed to this story