1.1 Introduction Local Health Departments protect the health of their communities by preventing disease and promoting policies and systems to ensure that the populations they serve can achieve optimal health. Local Health Departments (LHDs) typically provide clinical programs and services such as immunization services, screening for diseases and conditions, treatment of communicable diseases, and maternal and child health services. Most local health departments also provide population-based programs and services such as epidemiology and surveillance, health education, and environmental health services (NACCHO, 2016). LHDs are guided by the Ten Essential Public Health Services (Figure 1A) in the implementation of their mission, core functions, programs, and services. These ten essential services are: (1) monitor health status to identify community health problems; (2) diagnose and investigate health problems and health hazards in the community; (3) inform, educate, and empower people about health issues; (4) mobilize community partnerships to identify and solve health problems; (5) develop policies and plans that support individual and com-munity health efforts; (6) enforce laws and regulations that protect health and ensure safety; (7) link people to needed personal health services and ensure the provision of health care when otherwise unavailable; (8) ensure a competent public health and personal health care work-force; (9) evaluate effectiveness, accessibility, and quality of personal and population-based health services; and (10) research for new insights and innovative solutions to health problems.

Several factors are forcing LHDs in California to redefine their roles and responsibilities for improving population health. These factors are the implementation of the Patient Protection and Affordable Care Act (hereinafter referred to as the Affordable Care Act or ACA) in 2010, the expansion of Medi-Cal eligibility to 138% Federal Poverty Level in 2014, and the redirection of indigent medical care funding from counties to the state with the enactment of Assembly Bill 85 in 2013. In alignment with the Ten Essentials of Public Health Services, LHDs perceive themselves as the primary institutions responsible for identifying and addressing their community’s health concerns including linking or providing care to medically underserved populations. The residual number of uninsured people will challenge LHDs and force them to identify which of the safety net services will be needed to maintain amidst decreasing funding and increasing restrictions. Since Local Health Departments are the entities charged with identifying unmet needs, addressing gaps in service delivery, and reducing health disparities in their jurisdiction, LHDs need information to understand their role and options in the delivery of clinical services in the era of healthcare reform.

However, LHDs may lack the capacity to gather the data. Rural LHDs in particular may lack the resources to obtain data on the impact of the ACA and their provision of preventive services to the safety net population in their region. California has 58 LHDs operated by counties, and 3 additional city LHDs operated by Berkeley, Long Beach, and Pasadena. Of the 58 counties, 35 are considered rural as indicated by their participation in the Counties Medical Services Program, which provides limited-term health coverage for uninsured low-income, indigent adults that are not otherwise eligible for other publicly funded health programs. Of these 31 small counties, 48% of them has populations less than 50,000 and the remaining 52% has populations less than 200,000. Like all other LHDs, these small LHDs need to understand their role in the new public health system where more people are covered by health insurance, more people have access to preventive health services, and where there may be a decreasing need of a ‘safety net’ for medically underserved populations. However, small LHDs may lack the capacity to gather the information about the effectiveness of services offered by other safety net providers, such as Federally Qualified Health Centers, Rural Health Centers, private sector primary care providers, and medical facilities in their jurisdiction.

In a comparison of the workforce and training needs of rural public health departments to those in suburban and metropolitan areas, Hajat et al. (2003) concluded that collaborative approaches and regionalization are needed in rural jurisdictions to address the staffing shortage and program; and administrative training are crucial to promote effective and efficient delivery of public health services in rural areas. Since then, the ACA has transformed the existing health care system by providing unprecedented investments in the expansion of access to health insurance, community health centers, public health workforce, health information exchange infrastructure, patient-centered medical home, accountable care organizations, electronic health records, and prevention services. The passage and implementation of the ACA is a driving force for change in the current public health system (Bovbjerg et al., 2011). The recommendations of ACA for successful navigation of the changing landscape included evidence-base practice, defining value to foundational activities, and forming partnerships with diverse organizations. The implementation of the Affordable Care Act resulted in approximately 19.2 million nonelderly people gaining health insurance coverage from 2010 to 2015 (Garrett et al.

, 2016). In California, the ACA had expanded health coverage to millions of residents and improved coverage for millions more; but between 2.7 and 3.4 million people under age 65 were predicted to still remain uninsured by 2019, after the ACA is fully implemented.

Of those predicted to remain uninsured, approximately 50% remained ineligible for federal coverage options due to their immigration status (Lucia et al., 2015). Proposed modifications to the ACA is expected to increase the number of uninsured due to more restrictive Medicaid eligibility. The California Department of Health Care Services noted that the proposed American Health Care Act represents a massive shift in costs to states, which will increase the burden on the state safety net providers, and potentially increase uncompensated care costs in the populations of hundreds of millions and potentially billions annually (Kent, 2017). Under the current ACA, the Prevention and Public Health Fund expanded its access to primary care services via increased its funding to primary care service providers such as Rural Health Centers, Federally Qualified Health Centers, and school-based health centers.

Various blogs, briefings, and journal articles advocate reconsideration by public health departments to provide clinical services. However, if the ACA is repealed or replaced in the future, the number of uninsured will again increase and uncompensated costs will impact Local Health Departments. While networking with their state health department, key federal agencies, and nearby county health jurisdictions, Local Health Departments (LHDs) have the autonomy to form local collaborations and determine which health issues of particular concern and relevance to target within their communities. Local Health Departments are aware of the need for evidence-based strategic planning, especially as it pertains to identifying the effectiveness of their existing operations and developing partnerships with regional healthcare providers. 1.2 Current Situations in LHDs Many LHDs lack the time and resources to identify efficient and cost-effective services that can positively impact vulnerable populations.

A 2012 national survey undertaken by the National Association of County and City Health Officials (NACCHO) found that, in 14 states including California, 41% of LHDs had made significant cuts to staffing resulting in a reduction of population-based health services, such as population-based primary prevention and surveillance (NACCHO, 2014). LHDs in rural areas may face additional constraints including shortages of primary care providers, isolated communities, and lack of integration in existing healthcare providers. These constraints challenge underfunded and under-staffed the ability of rural LHDs to find new ways to ensure that core public health services are delivered and effective. In addition to the shifting landscape with the implementation of the ACA, LHDs continued to face funding and staffing challenges.

A 2012 national survey undertaken by the National Association of County and City Health Officials (NACCHO) found that 62% of California local health departments (LHDs) reduced or eliminated services in at least one program area; 20% of LHDs reported continued cuts in immunization services; and more than one-third (36%) of California LHDs lost at least one staff person due to layoffs or attrition in the previous year. The same study reported that California public health staff operated at a diminished capacity at 22% of all LHDs, either because their hours were reduced or because they were furloughed. Additionally, 24% of California LHDs expected their budget to be lower in 2013, continuing the trend of substantial percentages of LHDs experiencing budget cuts over the past five years (NACCHO, 2013). Using 1997 and 2008 data, Hsuan and Rodriguez (2014) found that LHDs are discontinuing clinical services over time. Those covering a wide range of core public health functions are less likely to discontinue services when residents lack care access. They concluded that future research is needed to examine the impact of ACA on the provision of clinical services by LHDs, especially in jurisdictions with residents still uninsured. While the ACA offers expanded access to healthcare for vulnerable populations, particularly preventive services, the impact in rural regions was unknown.

One uncertainty is the number of people who may continue to be uninsured by choice or by current eligibility restrictions. Similar to the study by Lucia et al., the California Health Care Almanac, published by the California Healthcare Foundation (2013) projects, indicates that one in five Californians will remain uninsured. However, the data projections are limited to only socioeconomic factors, and do not include county size or location.

Likewise, the report of California’s Uneven Safety Net by the Health Access Foundation in 2013 cites the CalSIMS projection of 3-4 million Californians remaining uninsured in 2019 and does not include projections of the uninsured in the 34 small counties. The Affordable Care Act established the Community Health Center Fund to provide $11 billion over a five-year period for the operation, expansion, and construction of health centers throughout the country (HRSA, 2012). In addition to the $1.5 billion set aside for capital improvements, funds are also provided to support primary care residency programs and the goal of providing high-quality and low-cost primary care. The additional investment is expected to reduce some of the challenges previously faced by safety net providers in caring for the uninsured, enhancing compensation for primary care providers, and expanding the community health center infrastructure. However, due to its size and location, small rural counties may not have community health centers nearby; and thus, another uncertainty is the access to available services due to limited capacity of Federally Qualified Health Centers, Rural Health Centers, and private primary care providers to accommodate the increased demand.

In addition, as more citizens acquire health coverage, more health professionals will be needed, especially in primary care. Rural locations may face increased competition for these professionals (Allen et al., 2013). A review of the impact of national health insurance on childhood vaccination in Taiwan shows that the increase in utilization of services is dependent on socio-demographics of the region and accessibility to services (Liu et al., 2002). The implementation of ACA is forcing local health departments to define the value of public health services and document gaps in the availability and accessibility of services due to the changing landscape in funding.

Because of these uncertainties, it is even more vital that all LHDs, but particularly small LHDs, develop a clear sense of their role within the changed healthcare environment and formulate innovative approaches that make the best use of existing resources in the provision of clinical services such as childhood immunization. Historically, LHDs primary role in this arena is to ensure the timely and effective delivery of immunizations services to children in their jurisdiction and direct delivery of immunizations to vulnerable populations (Ransom et al, 2012). Some of these activities are mandated by law, while others, such as providing vaccinations through public health clinics, are the result of local decision making. The estimated 94% of the population who will have insurance coverage beginning in 2014 may have immunization coverage as part of their package of care (Stewart et al.

, 2010). Although the impact of the ACA on LHDs vaccination and immunization activities remains unclear (Tan, 2011), LHDs will still need to consider how to extend coverage to those sectors of the population who will not be covered by the ACA, i.e., the undocumented workers and people who refused to buy private insurance. 1.

3 An Urgent Need Identified in LHDs Part of the calculation regarding the most effective and cost-effective way to provide services is the extent of cooperation that the LHD will have with healthcare providers in their jurisdiction. These providers, such as community health centers and school-based health centers, have received additional ACA funding, and expected to gain prominence in delivering primary care services to vulnerable populations. This creates new opportunities for LHDs to collaborate with    

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