1. Torney Smith Spokane, Washington

2.  Content I plan to cover The Washington state context for public health The public health system  Variability Funding origins and use Responsibilities and capacities Why is this important? Reasons that Washington State is doing the Foundational Public Health Services (FPHS) Foundational Public Health Capacities and Programs

3.  39 counties Home rule state  State Department of Health  35 Local Public Health Agencies Washington’s Public Health System

4.  Endorsement of a minimum package of public health services; defining the services and estimating the cost.  Development of a model chart of accounts to track public health spending  Doubling of the current federal appropriate for public health; a dedicated stable, and long-term financing structure to generate the enhanced federal revenue required to deliver the minimum package of public health services in every community; and greater state and local flexibility in the use of grant funds. IOM published FPHS report

5.  Establishing life expectancy targets, data systems for a permanent health-adjusted life expectancy target and establish a specific per capita health expenditure target to be achieved by 2030.  Public health should work with partners to develop adequate clinical care capacity in communities and state and local public health funding that is currently used to pay for clinical care should be reallocated by state and local governments to population-based prevention and health promotion activities conducted by public health departments. IOM published FPHS report

6.  Research to establish the effectiveness and value of public health and prevention strategies IOM published FPHS report

7.  Why did we in Washington do this? Public Health is a fundamental function of government–Most decision makers agree that public health is a basic responsibility of government, but what exactly does that mean? As public health funding has eroded dramatically, we have had to come to terms with the government’s basic public health responsibilities in a time of reduced resources. The public expects Washington’s public health network to work with health care providers, tribes, communities, and others to do what it can to improve health and reduce costs. Drivers of Change

8.  Why did we in Washington do this? The Revised Code of Washington (RCW) declares that “the social and economic vitality of the state depends on a healthy and productive population” and charges government with the “life and health of the people,” granting authority and responsibility for organizing public health services. Drivers of Change

9.  This work began with the goal to assure stable and adequate funding for public health. Folks realized that we needed to define what would be bought with the funding. We determined that we had two types of funding problems:  Quantity (insufficient funding) and Structural (broken or irrational funding system). Funding

10. Public health is becoming simply a collection of categorically funded programs. With major reductions in local and state funding, what was previously a weak foundation on which to add these categorical programs is now almost non-existent. So we set about clearly and tightly defining the Foundational Public Health Services that government (local and state) should pay for and deliver. Services that must be present everywhere in order for them to work anywhere (e.g., basic communicable disease investigation and contact tracing because disease does not recognize geopolitical boundaries). Structural (broken or irrational funding system)

11. The Foundational Programs and Capabilities

12. Foundational Capabilities are cross-cutting and support the foundational programs and are usually neglected by categorical funding: Assessment (surveillance and epidemiology) Emergency preparedness and response Communication Policy development and support Community partnership development Business competencies Foundational Capabilities

13.  Federal funds will continue to be categorical–In our thinking, most of these fall outside of the Red Box. They are “Additional Important Services” (AIS), represented on the diagram by the colored bars that extend beyond the Red Box–things that communities/counties would decide if they needed and wanted in their locale.  The FPHS framework is focused on what local and state need to pay for and deliver to provide the foundation and ongoing day-to- day work to protect the public. Structural (broken or irrational funding system)

14. The Additional Important Services

15.  State funding (statutorily-directed revenue) to ensure that the costs of FPHS are covered in every community (not every LHJ) Intent: change the funding structure (address the structural funding problem) State should fund the full cost of the Red Box (FPHS) $380.2 M/yr Locals can then shift the local funds they have been spending on the Red Box/FPHS to support specific programs and services they feel they need in their community and work with partners to also fund these.  State and local public health to design the allocation methodology and accountability system Who Pays for What?

16.  The field and practice of public health has been transformed in the past by: HIV/AIDS epidemic 9/11 And now by health reform  If we don’t adapt and evolve, public health will become irrelevant (extinct)  We must define our role in an integrated health system and with it, our future. Why is this important? Why now?

17.  Changing demographic  Changes in disease patterns  Health reform  Increasing regionalization–in other sectors of government and non-government Other Drivers for this work

18.  I am happy to dialog and/or answer questions Thank you Torney Smith Spokane Regional Health District Spokane, WA 99201 509-324-1518 tsmith@srhd.org