1. LOCAL PUBLIC HEALTH IN NORTH CAROLINA

2. NC Local Heath Departments “A county shall provide public health services.” GS 130A-34(a) Any countyCounties > 425K population County health departmentConsolidated human services agency District health departmentCounty department or CHSA governed directly by county commissioners (no BOH) Public health authority (single- or multi-county)

3. NC Local Health Departments

4. 2011 Legislation Five bills introduced, none passed yet, three still eligible for consideration: –S 433: Remove population cap to allow more counties to form consolidated human services agencies or abolish their local boards & transfer duties to county commissionersS 433 –S 552: Public health regionalization incentivesS 552 –H 438: County consolidated human services (New Hanover county only)H 438

5. 2011 Legislation Key issues in pending legislation: –County-level human services consolidation vs. public health regionalization –Governance by county commissioners vs. separate health boards –Authority vs. traditional department –Public health role as regulator as well as human services provider

6. Other activities & NC law Partial consolidations (single county) –No legal authority to merge or abolish boards for counties below population threshold –But also no prohibition on consolidating administrative functions of county agencies Inter-local agreements (multi-county) –GS Chapter 160A, Article 20 –County may enter on behalf of county health department, district health department or public health authority may enter on own

7. LOCAL PLAYERS AND ROLES

8. County commissioners Choose what kind of local public health agency and board the county will have –Board of health must agree to district or public health authority Appoint members of local board of health Authority to remove county board members –District and public health authority boards have authority to remove their members Approve fees set by board of health Approve local health department budget

9. Board of health role Protect and promote the public health Serve as the policy-making, rule-making, and adjudicatory body for public health in the county or counties it serves Oversee administration of the health department

10. BOH powers & duties Appoint the local health director* Adopt operating procedures Impose fees for some services Adopt local rules Adjudicate disputes about: –the interpretation or enforcement of local rules –the imposition of local administrative penalties

11. Operating procedures Required by accreditation rules Contents not specified in rules, but: –Must comply with state law –Must be reviewed annually

12. Imposing fees Boards of health may impose fees for some services Fees must be based on a plan that is: –Recommended by the local health director, –Approved by the board of health, and –Approved by county commissioners

13. FAQ: Approval of Fees Does the requirement of commissioner approval apply to district health departments? Yes. Fees must be approved by “the appropriate county board or boards of commissioners.” OK No way

14. Limitations on fees No fees when health department is acting as agent of the state (most EH programs) –Exceptions: on-site wastewater, swimming pools, tattooing regulation, local program for inspecting & permitting drinking water wells Regulatory fees must be reasonable (cost- based) Clinical fees generally reflect Medicaid reimbursement rates – patients may not be charged for some clinical services

15. No fees to clients for … Sickle cell testing and counseling Testing and treatment for TB and STDs HIV testing and counseling (but not treatment) Some immunizations for some children –Those required by law and supplied by the State must be provided at no cost to children from families that (1) have incomes below 200% FPL, and (2) are uninsured or underinsured Language assistance to limited-English proficient persons

16. Local rules BOH has authority to adopt rules to protect and promote public health A local BOH rule is a local law –Can be enforced against violators –Only applies within BOH’s jurisdiction – but applies to all counties and municipalities in BOH’s jurisdiction Must give public notice of intent to adopt, amend or repeal rules and follow other procedures set forth in law

17. Peedin test To be valid, a BOH rule must: 1.Relate to the promotion or protection of health, 2.Be reasonable in light of the health risk addressed, 3.Not violate any law or constitutional provision, 4.Not be discriminatory, and 5.Not make distinctions based on policy concerns reserved for legislative bodies.

18. State vs. local rules What if there’s a state rule addressing an issue a local BOH would like to tackle? –Local BOHs allowed to adopt a local rule that’s more stringent than state rule –Local rules may not be less stringent

19. What about state preemption? Chatham county hog farm case: –State law already provided complete and integrated regulatory scheme –But local BOHs specifically allowed to have more stringent rules even if state has acted –However, in presence of heavy state regulation, need a rationale for having local standards that exceed state standards

20. Adjudication Someone is aggrieved by a local health department’s interpretation or enforcement of a local rule, or the imposition of a local administrative penalty, so they appeal to the BOH, which acts as a court Procedures are in GS 130A-24 Key points: –Applies to local actions –Follow procedural requirements to the letter –Get help from attorney

21. BOH’s administrative role Appoints local health director Makes policies for local health department Reviews and transmits budget to county commissioners –Except consolidated human service agencies, which are specifically prohibited from doing this

22. Local health director 1.Administration a.Administer programs under direction of board of health b.Employ and dismiss health department staff c.Enter contracts on behalf of the department (subject to county oversight)

23. Local health director 2.May employ a number of remedies for public health law violations a.Public health nuisance/imminent hazard abatement b.Permit actions c.Administrative penalties d.Embargo e.Initiation of court actions to enforce compliance: i.Seek injunction (civil) ii.Pursue misdemeanor charges (criminal)

24. Local health director 3.Take action to control disease a.Investigate communicable and other diseases b.May order isolation or quarantine in appropriate* circumstances c.Enforce immunization requirements 4.Educate and advise a.Disseminate public health information b.Promote benefits of good health c.Advise local officials on public health matters

25. Public Health Services Laws that affect local health department services: –Mission and essential services of the NC public health system (GS 130A-1.1.) –Mandated services rules (10A NCAC Ch. 46) –Accreditation statute and benchmarks (GS 130A-34.1 & 10A NCAC Ch. 48)

26. Mandated services Provide:Provide/contract/certify: Food, lodging & institutional sanitation Adult health Individual on-site water supplyHome health Sanitary sewage collection, treatment & disposal Dental public health Communicable disease controlGrade-A milk sanitation Vital records registrationMaternal health Child health Family planning Public health laboratory