What public health systems legislation is the General Assembly considering?
North Carolina counties are required by law to provide public health services to their residents. Counties do this by creating or joining some form of local health department. For more information about the different types of local health departments that counties can operate or participate in under current state law, see this blog post by Jill Moore. In 2011, the North Carolina General Assembly considered several bills that, if enacted, could change the options that are available to counties in the future.
Three bills addressed county-level consolidation of human services (social services, mental health, and public health), and two made various proposals to promote or require the delivery of public health services through multi-county regions or districts. None of the bills was enacted, but three passed their chamber of introduction before the June 9 crossover deadline and therefore remain eligible for consideration during the short session scheduled to convene on May 16, 2012.
Two of the bills that made crossover (H 438 and S 433) would allow more counties to form consolidated human services agencies, and/or to abolish existing local human services boards and transfer their duties to county commissioners. One of the bills (S 552) would promote the development of regional public health authorities or multi-county district health departments. Below is a brief summary of the various bills, including variations and versions that have circulated in the past year.
Under current state law, counties with populations exceeding 425,000 (Wake, Mecklenburg, and Guilford) have two options that are not available to smaller counties.
- The county may form a consolidated human services agency, combining social services, mental health, and public health into a single agency governed by a consolidated human services board.
- County commissioners may abolish any or all of their local human services boards (including the board of health) and transfer the duties of the abolished board(s) to the board of county commissioners.
The original version of S 433 proposed to rewrite the state law to do three things:
- remove the population threshold, thus allowing any county to create a consolidated human services agency or transfer the powers and duties of human services boards to the county commissioners;
- allow a board of county commissioners that forms a consolidated human services agency to elect to make the agency’s employees subject to the State Personnel Act; and
- allow the commissioners of a county that forms a consolidated human services agency to choose to permit the consolidated human services board to appoint and supervise the agency director (under current law, the county manager appoints and supervises the director).
S 433 was amended several times during the Senate’s deliberations. Early in the process, there was a good bit of discussion about a federal law that requires agencies administering specified programs to have merit personnel systems meeting certain criteria. Consolidated human services agencies administer programs that are subject to that law. The State Personnel Act (SPA) creates a merit system that satisfies the federal law’s requirements, but a question arose about whether current county personnel policies do so, and the bill as proposed would allow a county to choose whether to make consolidated agencies’ employees subject to the SPA or to keep them under county policies. This issue was resolved by an amendment clarifying that all consolidated human services agencies must comply with the federal laws and rules regarding merit personnel systems. Thus, as amended the bill would permit a county that forms a consolidated human services agency to elect to place its employees under the SPA or under county policies that comply with the federal merit system requirements.
Two other changes were made to S 433 before it passed the Senate. First, a committee substitute for the bill included a section amending GS 153A-76, which addresses county commissioners’ authority to organize county government. Presently, the law prohibits the board of commissioners from changing the composition or manner of selection of local boards of health and social services. The proposed amendment would remove that prohibition from the statute. Second, an amendment adopted during the Senate floor debate removed the option for a county to permit a consolidated human services board to appoint and supervise the consolidated agency’s director.
As amended, S 433 passed the Senate on April 27, 2011. It was dormant in the House for some time, but during the last week of the session, a House committee considered and approved a committee substitute for the bill that retained the consolidation portions and added some provisions from S 552 (see discussion of the "combined bill" below).
This bill is more narrow than S 433. It would allow New Hanover county to exercise the options currently available only to the large counties. Specifically, New Hanover's county commissioners could
- form a consolidated human services agency, or
- abolish any or all of their local human services boards (including the board of health) and transfer the duties of the abolished board(s) to the board of county commissioners.
The bill passed the House on April 14 and was referred to the Senate Committee on State and Local Government.
As originally introduced, this bill would have created an incentive funding program for local health departments to form regional public health authorities composed of a minimum of 15 counties or containing a minimum population of 500,000 state residents. The original version of S 552 was never discussed in committee. Instead, on June 6, the Senate Committee on Health Care discussed and approved a committee substitute for S 552 that included “carrot” and “stick” financial proposals to promote the formation of local health departments serving populations of 100,000 or more:
- Carrot: Create the Public Health Improvement Incentive Program to provide monetary incentives for counties to create or join multi-county district health departments or public health authorities serving populations of 100,000 or more.
- Stick: By July 1, 2014, make state and federal funding for local health departments available only to accredited local health departments that serve populations of 100,000 or more (unless the State Health Director allowed an exception to the population requirement for good cause shown). In addition, most departments would have to organize as a public health authority or a district health department, but a grandfather clause would have permitted consolidated human services agencies created before January 1, 2011 to retain funding.
Additional provisions would have: (1) required the counties comprising each local health department to appropriate a minimum amount of funding to the local health department; (2) rewritten the state law that establishes the mission and essential services of the public health system to conform with the state’s local health department accreditation law, by reflecting the nationally recognized ten essential public health services that serve as the touchstone for the accreditation program; (3) directed the General Assembly’s Program Evaluation Division to study the feasibility of transferring the Division of Public Health from the NC Department of Health and Human Services to the UNC Healthcare System; and (4) allocated $5 million for the incentive program.
The provisions outlined in the bullet points above proved quite controversial, especially the portions that would have required county health departments to meet minimum population requirements and reorganize into public health authorities or district health departments in order to retain funding. The bill was amended twice on the Senate floor to address the population requirement. First, the population threshold was dropped to 75,000 for both the Public Health Improvement Incentive Program (the carrot) and the July 2014 requirements for state and federal funding (the stick). A second amendment retained the 75,000 population threshold for the incentive program but eliminated it from the funding requirement.
As amended, the bill passed its third reading in the Senate on June 9. It was sent to the House and referred to the Committee on Health and Human Services. The House did not act on S 552, but portions of the bill were incorporated into a House committee substitute for S 433—the “combined bill.”
The Combined Bill (S 433, Edition 4)
The combined bill would do all of the following:
- allow any county to create a consolidated human services agency or transfer the powers and duties of human services boards to the county commissioners.
- provide incentives for counties to form public health authorities or district health departments serving populations of 75,000 or more.
- Allow a board of county commissioners that forms a consolidated human services agency to elect to make the agency’s employees subject to the State Personnel Act.
- Clarify that consolidated human services agencies must comply with the federal laws and rules regarding merit personnel systems.
- Amend GS 153A-76 by deleting the provision that states that a board of county commissioners may not alter the composition or manner of selection of boards of health or social services.
- Require counties to appropriate funds to local health departments at levels equal to the amounts appropriated in fiscal year 2010-11.
- Rewrite the state’s public health mission and essential services law to conform to the essential public health services reflected in the state local health department accreditation law.
- Study the feasibility of transferring the Division of Public Health from NC DHHS to UNC Healthcare.
What happened with the combined bill? This is where things start to get a bit confusing.
- The full House was scheduled to vote on the combined bill on June 15, but the bill was withdrawn from the calendar and sent back to committee.
- When the General Assembly met again in late November, the committee discussed the legislation again and voted to (1) withdraw the combined bill from consideration and (2) ask the House to vote on the version of S 433 that passed the Senate in April of 2011.
- When the issue came up for discussion in the full House, the members voted against taking up the version of S 433 that passed the Senate.
When the General Assembly reconvenes later this spring, all of the options discussed above and potentially others may be on the table for debate, amendment and possibly adoption.