Local public health in north carolina

1. Local public health in north carolina

2. NC Local Heath Departments • “A county shall provide public health services.”GS 130A-34(a)

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 commissioners • S 552: Public health regionalization incentives • H 438: County consolidated human services (New Hanover county only)

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 beapproved by “theappropriate countyboard or boardsof 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. Peedintest • To be valid, a BOH rule must: • Relate to the promotion or protection of health, • Be reasonable in light of the health risk addressed, • Not violate any law or constitutional provision, • Not be discriminatory, and • 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 • Administration • Administer programs under direction of board of health • Employ and dismiss health department staff • Enter contracts on behalf of the department (subject to county oversight)

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

24. Local health director • Take action to control disease • Investigate communicable and other diseases • May order isolation or quarantine in appropriate* circumstances • Enforce immunization requirements • Educate and advise • Disseminate public health information • Promote benefits of good health • 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