State shares outside firm’s findings on local public health

Following the statewide consolidation of Public Health and Human Services to a single agency in 2022, Health Management Associates, a healthcare consulting firm from Minnesota, began conducting a review of the delivery of health and human services (HHS) in Iowa. During the Jan. 11 Jasper County Board of Health meeting, administrator Becky Pryor highlighted some areas where county residents may be affected by the firm’s recommendations.

“I see a theme within this that the recommendations come down to them recommending 10 to 15 regions comprised of counties that are by each other and they need to have a population of 50,000 or more,” Pryor said. “We have a population of 37,000 to 38,000 people. That means we would have to be with another neighboring county. Also, this isn’t saying they are doing anything yet, these are all just recommendations made by this company.”

After really digging into the almost 200 page document, Pryor found a table that assessed different states in the county and how they do public health. It ranged from having a local county board of health to the state having control of public health.

On the side of more control, the firm has a regionally administered centralized governance model based on Arkansas. In this model, HHS would provide administrative, policy, managerial direction and support and Local Public Health Agencies (LPHAs) would be organizationally a part of HHS. Other features include the establishment of a local presence in each county staffed by state employees. Local boards of health would be eliminated, but each county would appoint a county health officer to enhance local input, engagement and collaboration. HHS would create 10 to 15 multi-county administrative districts accountable for the effective, efficient and equitable allocation and use of public health resources and for ensuring foundational public health services and capabilities are available in all parts of the state.

The firm found advantages of the least local control model are it ensures more consistent public health service levels across the state, has the potential to generate efficiencies/eliminate duplicative efforts, potentially allows quicker response to emerging challenges and needs and is the simplest option.

Disadvantages include the potential to lose current local partnerships, individual county needs may not be a priority, the loss of county funds currently devoted to public health activities and the elimination of local boards of health and current LPHAs not consistent with the majority of stakeholder feedback during town halls and group interview and significant expansion of state workforce required.

“They still want local people in the county serving but it all says 10 to 15 regions,” Pryor said. “It really talks about eliminating the board of health and it would appoint a county health officer in each county.”

The second model based off of Nebraska and Idaho would again establish 10 to 15 regional health districts but they are governmental entities that are not state agencies or units of county government. The districts are required to maintain a local presence in each constituent county, are the governing body for local public health and the only governmental entity eligible for Iowa’s Essential Public Health Services funding.

Local boards of health will again be eliminated, but district governing boards will be comprised of members appointed by the constituent counties. Districts may employ staff and contract for services, counties could be required to financially contribute to the districts and the districts would be accountable for the effective, efficient and equitable allocation and use of public health resources and for ensuring foundational public health services and capabilities are available in all parts of the state.

Advantages include the model ensures more consistent public health service levels across the state, the potential to generate efficiencies/eliminate duplicative efforts and potentially allows quicker response to emerging challenges and needs. Disadvantages found were the potential to lose current local partnerships, but less so than the first option, smaller counties in the districts with larger counties may feel their needs are not a priority and the elimination of local boards of health and current LPHAs not consistent with the majority of stakeholder feedback during town halls and group interviews.

The third model based on Minnesota was found to be the most complex and would require counties to join a regional health district, subject to geographic and population size criteria for each district. The districts would be required to maintain a local presence in each constituent county, the governing body for local public health and the only governmental entity would be eligible for Iowa’s Essential Public Health Services funding, the counties could choose to retain local boards of health and LPHAs; district governing boards comprised of members appointed by the constituent counties, local boards of health could be allowed to retain local ordinance powers for specified functions (e.g., control of public health nuisances), districts may employ staff, contract for services, and delegate to constituent counties, must meet geographic and population size criteria designed to create 10 to 15 districts and be accountable for the effective, efficient, and equitable allocation and use of public health resources and for ensuring foundational public health services and capabilities are available in all parts of the state.

Model 3 advantages are it ensures more consistent public health service levels across the state, has the potential to generate efficiencies/eliminate duplicative efforts and potentially allows quicker response to emerging challenges and needs. Along with being the most complex, disadvantages are the potential to lose current local partnerships, but less so than the first two option, smaller counties in districts with larger counties may feel their needs are not a priority and negotiation of affiliation agreements between counties and RHDs would be needed and could be complex.

The final and most local control option is based in Indiana and would maintain Iowa’s current home rule governance structure but HHS would provide technical assistance and financial incentives to promote LPHA consolidations and cross-jurisdictional sharing (CJS) arrangements. Features of this model are it maintains local control; counties retain authority for designating local presence/offices, LPHAs choosing to consolidate are required to maintain a local presence in each constituent county, LPHAs choosing to accept financial incentives would be held accountable for delivering (including through consolidations or CJS arrangements) the state-defined foundational public health services and functions and HHS would provide technical assistance and supports to LPHAs under a regional structure, comprised of 10 to 15 regions, including technical assistance in formulating CJS arrangements.

For this model, advantages are it maintains current local partnerships, incentivizes/promotes more consistent public health service levels across the state, efficiencies and quicker response to emerging challenges and needs and it is able to maintain/ incentivize county. For disadvantages, the firm found some counties may not respond to incentives to fully deliver foundational public health services and functions leaving some areas of the state under served, HHS retains the challenge of supporting and coordinating and collaborating with a large number of local public health units and it would be potentially less able to achieve efficiencies and eliminate duplicative efforts.

“It’s a home rule model and maintains the local control in the county but with the 10 to 15 regions,” Pryor said. “They say in the recommendations the HHS adopt 10 to 15 regions with population more than 50,000. They did specifically name a few counties that are accredited including Cerro Gordo which only has a population of 42,409, very similar to us. We’re actually the 17th largest county in the state.”

She said there would have to be a lot of Iowa code and staffing changes along with a whole new structure to make this happen. Currently, Pryor was told this would not happen in Iowa this legislative session.

“There is no HHS legislation for the 2024 legislative session directly impacting local public health,” Regional Community Health Consultant at Iowa Department of Health and Human Services Heather Bombei said. “HHS has recognized the feedback through the HMA report to take time, as well as feedback from local public health and other partners to advance additional HHS system development efforts.”

While there is no current efforts to make changes to Health and Human Services in Iowa, Pryor said the uncertainty is hard.

“When we are looking at planning for the future, it does make it very hard to know what to do,” Pryor said. “I am just doing what we have done in the past and trying to make the best of it. It is just hard.”