The Capitol Corner: August 12, 2010

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Public Health Commission Holds Second Meeting
By Scott Maxwell of Mathews & Maxwell, Inc.

The Public Health Commission met for the second time August 9th and heard testimony from six individuals with perspectives on where the agency should be situated within state government. Those who testified included:

Debbie Hall, Chief Operating Officer for the Division of Public Health. She led the DCH transition team when the Division of Public Health transferred to DCH from DHR. She discussed the various complexities of moving a Division the size of Public Health from one agency to another.

Clyde Reese, III, Commissioner of the Department of Community Health. He, too, discussed structure of organizations and how decisions are made and budgets are set. He noted that the structure of public health — a combination of local employees at the county level and state employees at the district and state level – can cause “legal” problems. Employees of a county health department technically work neither for the county nor the state, but for the Board of Health. However, the funding for their salaries and programs is generally state and/or county dollars. (Commission members and later speakers repeatedly cited that same structure as one of the real strengths of public health in Georgia.)

Dr. Frank Shelp, Commissioner of the Department of Behavioral Health and Developmental Disabilities. He took over last year as Commissioner of a brand new department created at the same time Public Health was moved from DHR to DCH. He made the following points among others:

  • Attached agencies usually work best when they are not too large, their budget process is not overly complex, and much of their funding comes from federal sources or fees.
  • An independent agency has higher visibility and access – access to talk to legislators, the Governor, the public, federal officials, and in his case, even the Judiciary.
  • An independent agency is able to recruit talent from a different strata of individuals, and can more easily justify the salary required to get “innovative, can-do” people.
  • An independent agency has more accountability and flexibility, quicker reaction time, the ability to set its own priorities and to alter resources.
  • The priorities of a division or other small subdivision never make it to the top of the list of the parent organization. (He cited Information Technology as an area where this was especially true.)

    Shelp was asked how he would feel about Public Health becoming a part of his Department. He said he could make arguments on both sides of that issue. His concluding point was that the best economy of scale calls for combining some groups, but if too many groups are combined, you set the stage for creating another level of command and you’re back to where you started.

    Dr. Doug Skelton, Coastal Georgia District Health Director. As a former head of several state agencies, Skelton talked about the layers of administration and the importance of autonomy. He said that someone at the Commissioner level has better opportunity to shape policy. He also made the point about better access for an independent agency and added to Shelp’s list, improved access to the Office of Planning and Budget and the House and Senate budget offices. He did point out that a commissioner of an independent agency generally serves at the pleasure of the Governor and thus continuity of leadership can be a potential problem. Skelton was one of several who said the county/district/state structure of public health was one of its strengths. He pointed out that public health serves ALL Georgians.

    Russ Toal, Clinical Associate Professor at Georgia Southern University and Chairman of the McIntosh County Board of Health. Toal, who was the first Commissioner of DCH, discussed the distinction between an organization like public health that is geared to make decisions on the local level and a top-down organization where local people execute a statewide plan. He stated that public health should have a broader reach and impact and should not be kept in a silo. Toal stated that GPHA had three principles as priorities during consideration of HB 228, the human services reorganization bill. To wit:
    Public Health needs:

    • Autonomy – especially in a crisis and especially at the local level
    • Access – this follows autonomy and includes access to the Governor, legislators and scientists.
    • Authority – Statutory and regulatory. The authority to respond quickly to developing problems.

      Toal made the case that being an attached agency to DCH should be carefully considered. He argued that if the legislation is written correctly, an attached agency could enjoy those aspects of an independent agency mentioned by Shelp and Skelton, but also maintain ties to DCH and thus the Medicaid program and State Health Benefit Plan. Being “attached” would mean a potential savings in the number of people needed to do administrative tasks such as budget preparation, requests for proposals, and procurement. One of the architects of the human services reorganization bill, Toal emphasized several times that autonomy, access and authority for public health could be written into the legislation if it became an attached agency.

      Dr. Bob Stolarick, GPHA Executive Director. He made a presentation on the relationship between state health rankings and organizational structure. His slide show featured a breakdown of state health departments into three groupings by structure: “Stand Alone,” “Mixed Function,” and “Umbrella.” Various elements such as state and federal funding were placed in each category for comparison. His conclusions were:

      • Structure should follow strategy.
      • You have to spend money to make money.
      • Listen to what Public Health Employees have to say.
      • This is data and needs more analysis.
      • A move toward “stand alone” seems reasonable: if feasible, sustainable and timely.

      Following the presentations, Dr. Phil Williams, Chairman, divided the Commission into four subcommittees to give more intensive study to individual structural possibilities. Those are:

      Move Public Health to a different agency (possibly BHDD)
      Greg Dent and Ted Holloway

      Leave Public Health as a Division of DCH
      Deb Bailey and Jack Chapman

      Make Public Health an attached agency (probably to DCH)
      Lynn Feldman and Jim Peek

      Make Public Health a totally independent agency
      Diane Weems and Jimmy Burnsed

      The next meeting will be held on September 13. The tentative agenda is to have testimony from two legislators, Rep. Mickey Channell and Sen. Renee Unterman. Also testifying will be various individuals with expertise in the state budget.