Thursday, December 26, 2013

A Prosperous New Year?

Because of declining federal support and flat tax revenues, the State of Michigan is under intense pressure to operate more efficiently. Consider this: for every function it performs - public health, mental health, human services, emergency preparedness, etc. - the State is divided in a different set of regions. There are many dozen such regions with different numbers of units, different boundaries and different principles of governance. Many people agree this situation is inefficient and wasteful. No matter who the governor is, he or she would almost certainly want to align the various regions. This is exactly why our innovative Governor Snyder has proposed to divide the state into ten Prosperity Regions with which he wants State agencies to align their services. Here is a map of Michigan's 43 local health departments (LHDs). Notice that 30 are single county and 13 are district health departments with multiple counties.



And here is a map of the 10 envisioned Prosperity Regions. Notice that the Mid-Michigan District Health Department (MMDHD) is in 3 different Regions.



Will Michigan one day have only 10 LHDs contiguous with the Prosperity Regions? Recently the Executive Committee of the Michigan Association for Local Public Health (MALPH) met with the leadership of the Michigan Department of Community Health (MDCH) to discuss funding for LHDs for the coming year. We talked about many things, including the likelihood the Governor's grants for community-based prevention programs called 4x4 ("Four-by-Four"), will not be restored, as well as a proposal to involve LHDs in outreach and enrollment when Medicaid expands in April. But what I want to write about in this post are some thoughts I have had about the Prosperity Regions. In the meeting, MDCH leadership told MALPH that Prosperity Regions are likely to become a reality and that we need to start thinking about how to adapt to them. The question I want to discuss here is, "How will implementing Prosperity Regions impact public health?"

One way of looking at it is that aligning LHDs with Prosperity Regions could save public health. If State funding available to LHDs must continue to fall, then one way to maintain an adequate level of services is to consolidate or regionalize them to save on administrative costs. Actually, local public health has been doing this for years. MMDHD includes three counties (Clinton, Gratiot and Montcalm) that have been served by a single district administration for over 40 years. By consolidating Michigan's 43 LHDs into 10 we could, in principle, save money. When I explained the concept of Prosperity Regions to front-line staff recently, I told them, "Don't worry, this won't affect your jobs. There will still be the same number of wells and WIC clients in each county after Prosperity Regions." But then I pointed to administrative staff in the room, including myself, and said, "The idea is to get rid of our jobs." And so it is.

Others are not so certain administrative savings will be realized. They point out that the span of control of supervisors and directors will remain about the same. For example, every 7 to 10 nurses or sanitarians will still need a supervisor regardless of consolidation. Every 4 or 5 supervisors will need a Director. They argue that historically, savings have usually been realised in one of two ways: leveraging technology or cutting services.

I do think Prosperity Regions could improve local public health in some places. In some small single-county LHDs, Boards of Commissioners may be unable to fund adequate levels of services. If these counties joined better-endowed districts, the quality of the services provided could improve.

So how do we get to Prosperity Regions? This is the big question. In the Public Health Code the authority and responsibility to form LHDs - including district health departments - lies with counties - specifically Boards of Commissioners - not the State. The State cannot tell a county, "For the purposes of public health you are now part of district 'X'". Only County Boards can do this by creating Intergovernmental Agreements (IGAs). So if the Governor wants counties to rearrange themselves to conform to the Prosperity Regions, he either has to have a big carrot or a big stick. I question whether the carrot can be very big. The reason we are contemplating all of this is because of the money we don't have. As for a stick, the Code requires the State to support the health of the public. There will probably be no threats to defund services.

Think about this: current district health departments were created after long and difficult negotiations between counties. To craft their IGAs the Commissioners had to deal with:

  1. Governance. Counties had different ideas about delegating their authority and had to craft mutually acceptable new forms of governance. 
  2. Politics. Some counties favored a more forward-leaning regulatory environment, and some did not. A high degree of trust was required for Boards to join a single regulatory regime. 
  3. Finances. Counties' fortunes vary widely. To form districts they had to create funding formulas that seemed fair to all. 

To say the least, it will take a lot to get counties to abrogate existing IGAs and align with Prosperity Regions. MMDHD has experience with this. On three different occasions MMDHD and the Ionia County Health Department have tried to merge and we failed each time. The reason was always that our finances - how appropriations are determined, pay scales, etc - were so different that we realized it would actually cost all four counties money to merge. We couldn't propose a sure money loser to the Boards. But I think politics may be the biggest hurdle. For example, the Governor's plan envisions Clinton County in a single district with Ingham. Clinton has a majority Republican Commission with a light-touch local ordinance. Ingham is almost all Democratic with an aggressive regulatory regime. Will Red or Blue Boards really be willing to dilute their authority by merging?

Another approach would be to change the Public Health Code to strip counties of the power to create district health departments, and make public health more like Human Services where all employees work for the State. But such an approach would have to go through the legislature, where most representatives started as County Commissioners, and count on local votes to get re-elected. It isn't clear to me that the legislature would agree to usurp local control.

To move things forward, the State is asking LHDs to experiment with the idea of Prosperity Regions. So far I'd say what we've learned is that, when it comes to Prosperity Regions, we should either go all the way or not bother. In-between is a bad idea. For example, the State recently released small grants for training on household lead awareness. The grants were released to the core counties in each Prosperity Region. So MMDHD got contacted three different times by health departments in our adjoining Regions and asked to participate in their three grants. As the grant suggested, the first LHD to contact us offered to train our staff in exchange for our support. We agreed, but had to tell the second and third that our staff only need to be trained once. Instead they agreed to train staff of local community-based organizations. But arranging that will make a lot more work for us for which we won't be paid. This is not more efficient than just getting one grant. But my real beef with this approach is that it is not addressing the main hurdles that have to be crossed to get to Prosperity Regions, which, as I mentioned, have to do with cost of government at the county level. To solve Prosperity Regions you've got to solve county finances.

So this is my worry about how the move toward Prosperity Regions won't help public health. While we experiment with it, we could spend a lot of time doing things in ways that aren't rational, before we finally confront the fact that the existing structure isn't going to change. Look back over my earlier posts and think about all the things we need to be doing in this era of rapid transformation. Public health cannot afford to take it's eye off the ball.

And here is my final worry: that Prosperity Regions may deepen, not reduce, regional inequality. Although Gratiot and Montcalm counties have an extensive history of collaboration on health issues, efforts to collaborate with the core counties of the envisioned Regions have not been so successful. Do they really want to solve our rural transportation problems, for example; do they really think rural poverty is as serious a social justice issue as urban poverty? For Prosperity Regions to truly address the health needs of these communities, the Regions will need to have strong guarantees built into their IGAs to protect the less well-endowed counties. These guarantees are built into many of the current IGAs and would need to be re-built from the ground up.