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HomeMy WebLinkAbout05 May JEFFERSON COUNTY BOARD OF HEALTH MINUTES Thursday, May 17, 2000 Board Members.' Dan Harpole, Member - County Commissioner District #1 Glen Huntingford, Member - Counry CommiJJioner DÙtr'ict #2 Richard U/qjt, Member - County Commissioner District #3 Geojfrry MaJci, Member - Port Townsend City Council Jill Buhler, Vice-Chairman - Hospital Commissioner District #2 Sheila rJ'7eJterman, Citizen at Large (Ciry) Roberta Frissell, Chairman, Citizen at Large (County) Staff Membm: Jean Baldwin, Nursing Serviæs Director Larry Fqy, Environmental Health Director Thomas Locke, MD, Health qflìær Chairman Frissell called the meeting to order at 1:30 p.m. All Board and staff members were present with the exception of Member Westerman. Commissioners Wojt and Huntingford arrived shortly after the meeting began. PUBLIC COMMENT - None OLD BUSINESS FOLLOW-UP REPORTS: Smokeless States Grant and Syringe Availability Brochure. See reports. INFORMATIONAL ITEMS: Public Health Then and Now: Don Quixote, Machiavelli, and Robin Hood. (See article) NEW BUSINESS CRITICAL HEALTH CARE ACCESS PROJECT: Dr. Tom Locke recommended the Board use the Current Situation Report as a reference and highlighted sections that will be relevant in discussions with the Hospital Commission. He said it is important for the Joint Boards to review their respective roles and responsibilities. Thought also needs to be given to defining access and determining the role for the local Board of Health in ensuring that access. The major factors influencing access are the level of poverty, percentage of income from transfer payments, and death and birth statistics. The section on the Health and Medical Care System, beginning on pg. 11, will also be important for joint discussions. Member Masci questioned whether the COGME standards are a realistic comparison for Jefferson County? Dr. Locke agreed that the standards do not reflect the real situation nor do they consider alternative health providers. He believes it is more important to understand the health needs of the given HEALTH BOARD MINUTES - May 18,2000 Page: 2 population and determine whether they are being met. For the access project, one of the important goals is to get the most current data. He believes it will be difficult making policy decisions with the instability of health care. The rapid changes affect the ability to get good measurements. Commissioners Huntingford and Wojt joined the meeting. Commissioner Wojt asked if the statistics in the current situation report on page 15, referred to bed usage as opposed to bed availability? Vice Chairman Buhler said the average census is 12 beds and the hospital projects that number will increase to 17. She said the Hospital Commission determined that its number of beds is not conducive to going to a Critical Access designation. Dr. Locke said another area he believes the Joint Board will be dealing within the months ahead is the financial mechanism for medical care funding (pg. 17). Eighty-one million is spent for medical care services for Jefferson County, representing nearly 15% of total local economy. Although this figure is close to the national average, it is still substantially higher than any other industrialized nation. Medicaid rates in Jefferson County (pg. 19) are below statewide averages even though average income is also below statewide levels. Health Nurse Julia Danskin reported that between 1997 -1999 many people were dropped from medical assistance when they continued to qualify - so it is likely those numbers will rIse. Dr. Locke said there is a grant proposal before the Washington Hospital Foundation for a workgroup to come up with detailed options. Most important to the Joint Board will be accurate, up-to-date, and hopefully, statistically meaningful statements on needs and various options for better meeting those needs. Commissioner Huntingford said if individual doctors cannot survive financially, how does the hospital plan to pay the doctors and continue to provide access? Vice Chairman Buhler responded that the hospital is trying to increase market share and is looking at different ways of reimbursement. The hospital will hold on as long as possible with its goal of providing health access for everyone. She said it is important to understand that the hospital is not subsidizing physicians, but access to healthcare. BOARD OF HEALTH LEADERSHIP CONFERENCE REPORT: Dr. Locke's conference report is included in the agenda packet. He commented that Mary Selecky gave a particularly good presentation on "The Role of Government in Public Health" and the round table discussions worked well. Chairman Frissell felt the conference was excellent and well worth the time and encouraged future attendance. She summarized the presentations given on the second day of the conference. Particularly interesting was Ree Saylor's presentation on Governor Locke's Health Policy which she highlighted as follows: . Public health takes a systems approach in contrast to the rest of the healthcare system -- double digit inflation is eating up the system. HEALTH BOARD MINUTES - May 18,2000 Page: 3 t They anticipate the next budget will require 45 cents of every new healthcare dollar to maintain the present system as compared to 30 cents in the current budget. t Creation of healthcare standards. t Support for more flexibility with funding and fewer restrictions on Federal dollars. t Universal childhood vaccinations are in jeopardy because of the cost of new vaccines. t Rising costs of prescription drug for seniors. t Prescription drugs are now 20% of the health budget compared with a previous 7%. t No plan yet for a dependable source of funding for public health. t Public health is the sole survivor of the 1993 Healthcare Reform. t A positive aspect of the trend of large employers going for defined contribution plans is that it is moving us toward a prevention focus. t Budgets are going to get tighter. The Federal Government is giving grants to 10 States for new blueprints for delivery, although they will not pay for direct services in the grants. t To build trust, we have to defeat ignorance, especially with State Legislators. Dave Knudson, Senior Research Analysis for the State House of Representatives Healthcare Committee, reported the following: t The budget approved this session was seen as a bridge until after the election. t Individual health insurance will be available by the end of the year as well as a review of pharmaceutical drugs. t Implementation of changes in wages for caregivers will be monitored by the State. t The House and Senate are reviewing the mental health delivery system. t The final word on 1-695 has not been written. t Legislators have not established priorities for spending and have no long-range strategic plan. Mr. Knudson recommended that local Boards of Health talk with legislators about local issues, show them programs in action, have a presence in Olympia, give each legislator a point of contact for questions and information, offer solutions and identify specific outcomes. Commissioner Harpole said he found particularly interesting the chart on funding by local health jurisdictions that it says good things about Jefferson County. Jean Baldwin said the figures are deceiving and that the County comes out more in the middle when considering the expanse of services. Chairman Frissell mentioned she has an additional report on the impacts of MVET loss on local public health department districts. AGENDA PLANNING AND BOARD RETREAT: Jean Baldwin reported Mary Selecky is scheduled to attend the next Board of Health meeting on Thursday, June 15 at 1:30 p.m. Legislators and Ree Saylor have also been invited. She requested input from the Board on structuring the day. HEALTH BOARD MINUTES - May 18,2000 Page: 4 The Board discussed various options and agreed that although there is a need to educate legislators, it was premature to outline specific priorities for them. The Board agreed to use the July Retreat for priority-setting exercises. It was suggested that when the legislators visit, possibly later in the summer, that there could be presentations with priorities clearly outlined. Presentations would have added impact if there was a symmetry on the major issues with other public entities such as the Economic Development Council, local Chambers of Chamber, Hospital, and Olympic Area Agency on Aging. Jean Baldwin, Chairman Frissell and Dr. Locke will structure the agenda for the June meeting. The discussion about local rural healthcare access with Mary Selecky will be in the latter part of the Board of Health meeting and will include the Hospital Commission. The Board Retreat will be held on Thursday, July 20 from 1:30 p.m. until 5:30 p.m. in place of the regular monthly meeting. The location will be Chairman Frissell's residence, with lunch beginning at 12:30 p.m. Dr. Locke, Jean Baldwin and Chairman Frissell agreed to prepare the retreat agenda. Ideas for retreat topics include local Board of Health priorities for next year in relationship with State funding, review of rough draft on performance-based budgeting, and the performance, partnerships and catalectic leadership presentation. There was agreement to cancel the Joint Board meeting in July. WASHINGTON STATE IMMUNIZATION SYSTEM FUNDING CRISIS: Dr. Locke reviewed the problem that the State does not have an ongoing source of funding for the mandatory set of vaccinations available through a universal access system. He reviewed the current funding structure and the goal of coming up with a long-term strategy. Further complicating the funding problem is the projected list of new vaccines has increased. The original rationale for public funding of vaccinations was to protect the public against outbreaks. A number of new vaccines are moving into preventing diseases which have personal health impacts, but negligible community-wide impact. Prevnar is one vaccine that is now approved and will cost $240 per child -- more than the current seven mandatory vaccines put together. There are some vaccines coming beyond 24 months that would address epidemic diseases. While the rate of vaccination is increasing, the number of distributed doses is decreasing. This represents a significant achievement in preventing waste. Dr. Locke suggested that by June, the Board may want to take a position on the immunization issue and present it to Mary Selecky. The State Board of Health has convened a task force that has nearly completed a long-term funding strategy for immunizations. They have already agreed on the importance of maintaining universal access and the federal purchasing plan. They will soon present their proposal to the State Department of Health and Governor Locke. INFANT DAY CARE: Commissioner W ojt said it has been brought to the attention of the County that there is a critical lack of child care providers. The problems associated with the decline in childcare providers are lack of suitable locations, poor pay, and poor training. He believes this crisis has mental, physical, and economic ramifications for the community health and that childcare is directly connected to giving children a good start in life. Jean Baldwin said there is also huge issue of communicable diseases at daycare. The Health Department has a number of programs to help assist the public that may need to be better publicized. She said this is a problem where more detail is needed and may be a good retreat topic. Commissioner Harpole said a strong economy and low unemployment is pushing the crisis. HEALTH BOARD MINUTES - May 18, 2000 Page: 5 INITIATIVE 725: HEALTH CARE 2000: Commissioner Harpole asked whether this item is going to be tabled? Chairman Frissell said tabling the item to next month may not be appropriate due to its timeliness. However, with the absence of Dr. Melanie McGrory this issue will be discussed at a later date. APPROVAL OF MINUTES Member Masci moved to approve the minutes of the April 20, 2000 meeting. Commissioner Huntingford seconded the motion. Commissioner Harpole noted that on pages 1 and 2, corrections should be made to reflect that Commissioners Wojt and Harpole were late to the meeting, not Commissioner Huntingford. The motion was amended to include the corrections on pages 1 and 2 and the motion carried by unanimous vote. ANNOUNCEMENTS - None AGENDA CALENDAR/ADJOURN Mary Selecky visit, Joint Board Meeting - June Board of Health Retreat 12:30-5:30 - July Solid Waste Ordinance and State Board of Health Update - August Meeting adjourned at 3:40 p.m. The next meeting will be held on Thursday, June 15, 2000 at 1:30 p.m. JEFFERSON COUNTY BOARD OF HEALTH ,} , 1.-' /ti:(u:{{;i ~;úW(( Roberta Frissell, Chairman ()};/8~C/'- ~uhler, Vice-Chairman ~ngford, ,fJt.)ir1r (Excused Absence) Sheila Westerman, Member Erin Lundgren BOCC Office PO Box 1220 Port Townsend, WA 98368 County Health & Human Services May 9, 2000 To: Jefferson County Board of Health Subject: Tom Locke, MD. MPH, Jefferson County Health OfficerJE~F ' B ,ERSON COUNTY Board of Health Meeting - Thursday, May 18,2000 OARD OF COMMISSmNERS From: The next meeting of the Board of Health will be held on: Thursday, May 18,2000 1:30 - 3:30 PM Jefferson General Hospital Auditorium (Joint Board meeting follows from 3:30 - 5:30 PM) Enclosed are a tentative agenda for this month's meeting, draft minutes of the last Board of Health meeting, agenda materials and the department's monthly media report. · Follow-up Reports/Informational Items: Smokeless States Grant Syringe A vailabilitv Brochure Public Health Then and Now · Initiative 725: Health Care 2000: Dr. Melanie McGrory will continue her presentation from April's meeting, supplemented with additional written information about this citizens initiative. A legal opinion is included from David Alvarez, Jefferson County Deputy Prosecuting Attorney concerning the Board's ability to take a collective stand on ballot initiatives. · Critical Access Project and Public Health Care Standards: A request has been made that the Jefferson County Board of Health receive copies of the same information regarding critical health care access that the Jefferson General Hospital District Board of Commissioners received in November of 1999. Part of this information was distributed to the Board of Health prior to the fIrst Joint Board meeting in late December. Attached is a complete copy of this report. This report will be discussed in preparation for the Joint Board meeting that will follow the Board of Health's meeting. Linked to this discussion will be a short presentation of the draft public health standard that defmes the role of local health jurisdictions in assuring access to critical health services. This standard is being developed as part of the Public Health Improvement Plan. This standard, combined with the Board of Health's statutory authority (RCW 70.05.060), provides a starting point for a discussion of the Board's role with respect to health care access in Jefferson County. · Board of Health Leadership Conference Report: Board Chair Roberta Frissell and Health OffIcer Tom Locke attended the May 4-5 Leadership workshop in Seattle. A few handouts of interest are included for the Board's review. An oral report of the meeting will be made. · Washington State Immunization System Funding Crisis: Washington State is one of only 11 states to have a "universal access system" for children's vaccines. This policy makes vaccine available without charge to all children within the state. This $21 million annual purchase of vaccine is accomplished through federal funds (68%) and state general funds (32%). The vaccine is purchased as part of a federal contract for substantially less than it would cost on the private market. This system has been an unqualifIed success and has resulted in high levels of immunization among young HEALTH DEPARTMENT 360/385-9400 ENVIRONMENTAL HEALTH 360/385-9444 DEVELOPMENTAL DISABILITIES 360/385-9400 ALCOHOL/DRUG ABUSE 360/385-9400 FAX 360/385-9401 children. Unfortunately, it lacks stable financial support. Added to the absence of a dedicated funding source for the current system is the prospect that new, very costly vaccines will further stabilize the system. A discussion will be held with the Board on how the current system works (and is funded), the serious challenges it faces, and the response of local and state health jurisdictions to this funding crisis. . Discussion Items: Board of Health Retreat: Several ideas were discussed at the April 2000 BOH meeting regarding scheduled retreats for the Board of Health and/or a Joint Retreat with the Hospital Board. An opportunity will be provided to refine this plan and possibly schedule dates. . Infant Day Care: Richard Wojt would like to initiate a discussion regarding the problems and possible solutions of infant day care availability in Jefferson County. If you have any questions regarding the enclosed agenda, or any additions to the agenda, please call me at 385-9448. JEFFERSON COUNTY BOARD OF HEALTH Thursday, May 18,2000 1:30 - 3:30 PM - Board of Health Meeting 3:30 - 5:30 PM -- Joint Meeting with Hospital Commissioners Auditorium, Jefferson General Hospital AGENDA I. Approval of Minutes of Meeting of April 20, 2000 II. Public Comments III. Old Business Follow-up Reports - Smokeless States Grant Syringe Availability Brochure Informational Item -- Public Health Then and Now: Don Quixote, Machiavelli, and Robin Hood IV. New Business 1. Initiative 725 : Health Care 2000 (20 min) Dr. McGrory 2. Critical Health Care Access Project (30 min) Tom, Jill 3. Board of Health Leadership Conference Report (20 min) Roberta, Tom 4. \Vashington State Immunization System (20 min) Tom Funding Crisis 5. Agenda Planning and Board Retreat (10 min) 6. Infant Day Care (10 min) Richard V. Adjourn Next Meetine: June 15, 2000 JEFFERSON COUNTY BOARD OF HEALTH MINUTES DRAFT Thursday, April 20, 2000 Board Members: Dan Harþoie, lvIember - Countv Commissioner Distnd #1 Glen Huntingjord, Member - Co;nty CommiJ"J"ioner DÍJtrict #2 Richard W'qjt, Member - County Commissioner District #3 Geoffrey Masd, Member - Port Townsend City Coundl Jill Buhler, Vice-Chairman - Hospital Commissioner District #2 S heih Weste/7J1an, Citizen at Lar;ge (City) Roberta Primll, Chairman, Citizen at Lar;ge (Coun!YJ Staff Members.' Jean Baldwin, Nursing Services Director Larry Fqy, Environmental Health Director Thomas Locke, MD, Health Officer DRA,¡:., Chairman Prissell called the meeting to order at 1:30 p.m. All Board and staff members were present with the exception of Commissioners Wojt and Huntingford who arrived after the meeting began. Chairman Prissell announced this month's joint meeting with the hospital commission was canceled because Dr. Locke was unable to attend. PUBLIC COMMENTS Dr. Melanie McGrory introduced Initiative 725 -- Healthcare 2000. The purpose of the plan is not to replace good plans that exist, but to pool resources and provide coverage for people not covered. As a primary care physician, her concern is that the majority of her patients are relatively under-insured or not insured at all. Those with insurance have high deductibles of $700 to $1,000 and, from a primary care point of view, they are uninsured. Her feeling is that the system is broken and needs an overhaul and that working within the current system is a losing proposition. A petition with signatures of 230,000 Washington registered voters is required for the initiative to move forward. She admitted that while the initiative may not be the perfect solution, it will open critical dialogue. She will forward more specific information on the initiative to the Board for review. Member Masci said whether or not this is the right solution as an initiative, it is going to have more livability and put people in direct control of their healthcare. Member Westerman said she believes it is appropriate for the Board of Health to take a position on the initiative. She requested a discussion of Initiative 725 be added to the next Board of Health agenda and that information provided by Dr. McGrory be included in the Board's packet. OLD BUSINESS 1999 .T efferson Countv Health Pro!!ram End of Year Report: See report. . HEALTH BOARD MINUTES - April 20, 2000 Page: 2 Local Board of Health Leadership Workshop: Chairman Frissell and Commissioner Wojt are expected to attend the May 4-5 workshop in Seattle. A report of the workshop will be reviewed at the next Board of Health meeting. NEW BUSINESS Svrin2e Exchan2e Pro2ram - Public Comment and Draft Resolution: Lianne Perron, representing the Prosecutor's Office, expressed full support of the Syringe Exchange Program (SEP), saying it has been well thought out and well planned. Suzanne Schmidt, Chair of the Substances Abuse Advisory Board, said they voted and wrote a letter of support of the SEP. They feel it will give them better access, knowledge and accountability as to the size of the problem. She introduced Dick Gunderson as the new coordinator working on many of these issues. Jean Baldwin distributed and read a letter from Dr. Tom Locke urging the Board of Health to vote in favor of disease prevention through the SEP initiative. (See attached letter that was read into minutes.) Milt Morris spoke in opposition to the planned program. Programs across the country and in Europe have failed to reduce the transmission of infectious diseases. The drug problem has grown as a result, and these programs are a taxpayer's nightmare. If an SEP is instituted, he believes the community will regret having created a network of needle users. Both the Chief of Police in Port Townsend and the Jefferson County Sheriff personally oppose the program. They do not believe it will prevent or protect their officers from being stuck by a needle in a pat down or decrease the number of discarded needles. There are no documented cases in this County of any infectious diseases being spread through the use of dirty needles. He does not understand what is to be gained by an SEP. Discussion and a decision on the resolution was postponed until Commissioners Huntingford and Wojt are present. Board of Health Retreat ¡Joint Meetings with Jefferson General Hospital: Chairman FrisselI said she and Dr. Tom Locke discussed ideas for providing more direction in joint meetings with the Hospital Board of Commissioners on the health access process. Chairman Frissell proposed a half-day Board of Health retreat to discuss health access or other objectives and what role each agency should play. Also, she asked if there is support for a facilitated all-day meeting with the Joint Boards with possible subcommittee work? Commissioners Huntingford and Wojt joined the meeting. There was agreement to intersperse the monthly joint Board meetings with some longer meetings. Jean Baldwin recommended key reports be presented by Dr. Locke, Jill Buhler, and Vic Dirksen at the next Joint meeting. Dr. Locke has agreed to present Board of Health governance issues. She supports having a retreat to start discussions on health care access as a public health issue. Chairman Frissell agreed to talk with Dr. Locke to place specific questions on the next Board agenda regarding HEALTH BOARD MINUTES - April 20, 2000 Page: 3 retreat topics. The Board also agreed to resume 1-112 hour Joint Board meetings next month with presentations from Dr. Locke and Vic Dirksen. If possible, the next Board of Health meeting will be held at the Hospital at 1:30 p.m. APPROVAL OF MINUTES Member Masci moved to approve the minutes of the March 16, 2000 meeting. Commissioner Huntingford seconded the motion which carried by unanimous vote. NEW BUSINESS - CONTINUED Continuation of Svrinl!e Exchanl!e Prol!ram - Discussion: Member Buhler said given all of the information and support from governmental and independent agencies for the SEP, she has to support the SEP. There may be a public mis-perception about the SEPs but the key word is "exchange." We are not giving needles to people who do not already have them, but are exchanging dirty ones for clean ones. Chairman Frissell pointed out that the Board is looking at this program as disease prevention, not as a moral or political issue. Commissioner Wojt asked how will this program will be funded? Jean Baldwin said supplies for the program are minimal with needles costing approximately $200 a year. Funds for the SEP would come from the AIDS Omnibus mv Prevention Program with 50% of the funds targeted to treat high-risk individuals. This is not new money, nor is any additional money being budgeted. Money and staffing time will come from mv testing and counseling of low risk individuals, which was cut by 50%. Commissioner Huntingford asked how much of a problem is needle use in Jefferson County? Ms. Baldwin reviewed the state, national statistics. She said two local sources of needle use came from Clallam County Jail and local treatment centers. Local Hepatitis C cases are unknown. She indicated most of the staff work has already been done in preparation of the program including a referral network. The program might involve an estimated 25 needle users. Commissioner Wojt moved to adopt the Access to Sterile Syringes and Needles Resolution. Member Buhler seconded the motion for discussion. Member Westerman said one of the reasons she was excited that the legislature made it possible to expand Boards of Health is because she felt it was an opportunity at a local level to de-politicalize public health. Commissioner Huntingford commented he is disappointed that the information the Board received did not reflect opposition voiced in the media. A vote was called for on the motion. Commissioner Huntingford voted "against" the motion with the remaining six (6) Board members voting "for" the motion which carried. ---., HEALTH BOARD MINUTES - April 20, 2000 Page: 4 Annual Food Service Awards: Seven years ago, these awards were recommended by the Food Service Advisory Committee as an opportunity to recognize efforts by food service establishments. The criteria established by the Advisory Committee are limited but can be difficult to adhere to. Establishme~ts have to be preparing potentially hazardous food and an array of foods that potentially exhibit a high risk to the public if handled improperly. Mr. Fay reviewed the point system by which the criteria were established. This year, there was a record number of 42 establishments receiving the award. A lot of establishments received consecutive awards, representing their commitment to food safety. Susan Porto said there are just over 100 eligible facilities. With the awards, Larry Fay recognized and thanked the following establishments for their exceptional efforts in maintaining our public health standards: 2nd year: Cheeks Bloomer's Landing Silverwater Café Lonny's Jefferson County Jail 5th year: PT Senior Nutrition Program Waterfront Pizza Upstairs The Valley Tavern Discovery View Retirement 3rd year: 4th year: 6th year: Mr. Fay recognized other organizations receiving awards this year as follows: Uptown Pub and Grill, The Village Baker, Upstage, The Geoduck, Sentosa Sushi, Safeway Deli, QFC Port Townsend Deli, The Pizza Factory, Niblick, MacKenzie's Deli, Maxwell's, KIm Larb Thai, Heron Beach Inn, EI Sombrero, EI Sarape, The Cellar's Market, Ajax Café, Stormin Norman's, QFC Port Hadlock Deli, the Tri-Area Senior Nutrition, The Portside Deli, The Lighthouse, Lanza's, Jordini's, Hard Rain Café, Brinnon Seniors, Seabeck's Pizza, Peninsula Foods Deli, Nancy's, Fat Smitty's, Bread & Roses, Whistling Oyster, and Java Port. On-Site Sewa2e Regulation .- Operation and Monitorin2 Inspection Program 8.15.160: The proposed Draft #4 incorporates comments from community meetings in Chimacum, Brinnon and Quilcene as well as from designers, installers, and homeowners and results in a blending of public and private sector models for 0 and M. Linda Atkins reviewed the benefits of the proposed model utilizing the PUD as the primary monitoring entity: · consistency of inspection and knowledge that inspections are being completed · significantly lower cost for monitoring and maintenance versus private contractor model. The PUD will be inspecting more components of the system than they currently perform · better control, with oversight of information · owner retains the right to choose the maintenance person · there is no vested interest or incentive to find problems · provides ability to tie PUD data into existing database (for permitting and tracking) · decision and relationship with the PUD. The County does not have to start from the ground up Commissioner Huntingford asked for an update on the County's communications with the PUD. Larry Fay indicated the PUD's main concern is conducting the initial inspection for an existing system. The County has agreed to design a program which places responsibility for the initial inspection and the establishment of future inspection schedules with the County. After the data is in the system, the PUD will begin to pick up future inspections. As outlined in the ordinance, at the time of building permit or sale of the property an inspection would be performed by Health Department personnel and the information would then be passed on to the PUD. . HEALTH BOARD MINUTES - April 20, 2000 Page: 5 Commissioner Huntingford asked what mechanism will be used by the County to hold up the sale of a house in order to have the septic system inspected? Linda Atkins responded the inspection would be a requirement of the sale of property. This would be communicated to all real estate agents and financial institutions in the County. It is conceivable that a property could change hands independently, between a buyer and seller without a real estate agent. If it is a cash sale, notification of the requirement would come at the time the sale is recorded with the auditor's office. To protect itself, the lending institution is not going to close until the requirements have been met. David Alvarez said although the vast majority of houses go through a mortgage process, he does not believe a "notice to title" can be legally enforced since the term is not referred to in the statute. Linda Atkins referred to the addition of Section (6) that specifically outlines reporting requirements and who can conduct an inspection. This addition should address the ongoing complaint that Environmental Health does not act fast enough when there is a property transaction taking place. Commissioner Huntingford questioned the specific reference to the Growth Management Act under (c) of 8.15.170. Larry Fay said this may need to be revisited, but the language came from On-Site Sewage WAC 246- 272. Larry Fay reviewed the Areas of Special Concern regarding the extra level of treatment for the Tn-Area. Appeals of Critical Area issues are done through the process of the Critical Areas Ordinance, not through the Board of Health. Member Masci moved that the Board of Health support staff recommendation relative to operations and monitoring and accept the PUD as the primary contractor. Commissioner Harpole seconded the motion which carried by unanimous vote. On-Site Sewa!!e Re!!ulation -- Vestin2: Linda Atkins reviewed the State WAC 246-272 as it applies to additions, remodels, replacement, and expansions. When the Department is dealing with an expansion, the on- site sewage system has to be compliant with current code. Member Masci believes that staff should establish reserve areas based on a review of the plot plan as well as a drive-by and/or visit inspection. He agrees that some record needs to be established on unknown sites for any building permit. Linda Atkins said under the current procedures, staff requires an evaluation of the existing system if there is no record of the site on file. Although it is staff's desire to continue this policy, the issue is that the site change may not have anything to do with the septic system. Staff claims that it may reduce the ability to repair the system or assure that the system is not currently failing. Larry Fay noted that as recently as six or seven years ago, staff did not even look at building permits if they were not associated with the residential septic system. When the state updated their regulations in 1995, staff, ---, HEALTH BOARD MINUTES - April 20, 2000 Page: 6 without changing policy, moved more aggressively into complying with the WAC onjnspections. Staff is fairly confident, assuming the system is working and within capacity, that anything permitted since 1992 _ or even post-1987, in most cases - is going to be considered compliant. Staff recommends keeping the language in the regulation as compatible with the State regulation as possible. You have to be in compliance with the on-site sewage code as of the time you apply for the building permit. In policy, staff will try to anticipate, define and list some of the variables to ensure the system is compliant with current code. In older systems, records will need to be updated as to whether the system is compliant. Based on the code at the time, staff wiU say the system was permitted for a certain use and determine if the system is still functioning and require establishment of a reserve area. Although the system may not be fully compliant with vertical separation, instead of a three- year inspection, staff could set up a one-year inspection frequency. If there are operational problems because of the differences between code and design standards, they will be found through the inspection process. Member Masci moved that the Board support staff's recommendation to retain revised Section 8.15.060 Adequate Sewage Disposal Required. Staff will continue developing a policy that states that on sites larger than 5 acres, establish reserve/repair area based on review of the plot plan and drive-by and/or visit inspection plan. For building permits on completely unknown sites, the establishment of a record is needed. Commissioner Harpole seconded the motion, which carried by unanimous vote. Larry Fay said that staff will prepare a clean, final draft and set up hearing dates and a process for adoption. AGENDA CALENDAR / ADJOURN Meeting adjourned at 3:45 p.m. The next meeting will be held on Thursday, May 18 at 1:30 p.m. at the Jefferson General Hospital Conference Room. JEFFERSON COUNTY BOARD OF HEALTH Roberta Frissell, Chairman Geoffrey Masci, Member Jill Buhler, Vice-Chairman Richard Wojt, Member Glen Huntingford, Member Sheila Westerman, Member Dan Harpole, Member Follow up Report Update 1: Smokeless States Grant (Robert Wood Johnson Foundation grant awarded through Washington DOC) Attached is a copy of the April 30, 2000 Peninsula Daily News display ad. This ad also ran in the Leader on 4110. This is one component of the Tobacco-Free Olympic Peninsula-Get Involved! campmgn. The objective of the smokeless states grant is to increase citizen awareness of the health effects and economic costs of tobacco related illnesses. Campaign goals include mobilizing youth and adult citizens of Clallam and Jefferson counties through intensive tobacco prevention and control public awareness campaign. Primary activities include "Tobacco Free Olympic Peninsula - Get Involved" youth art project. Entries were received from Clallam and Jefferson County elementary, middle, and high school age youth. Entry criteria included at least one tobacco fact and a tobacco free message. Youth who provide submissions will receive a certificate of recognition from sponsoring agencies. Selected youth artists were awarded $25.00 certificates for art supplies; selected submissions are slated for publication in local newspapers, and development into posters, and refrigerator magnets as funding permits. Included in display ad text is reference information regarding Washington State Tobacco Prevention & Control plan. Update 2: Syrin~e Availability informational brochure by the Lindesmith Center. This brochure has concise information pertaining to syringe availability, infectious diseases, public concerns and a plethora of references (many are on file at the Health Department.) \f :\' - Public Health Then and Now Don Quixote, Machiavelli, and Robin Hood: Public Health Practice, Past and Present A B S T RAe T ;' Since the mid-19th century, the fIrst fannal health departments established in the United States, missianers, directors, and secretaries public health have functianed as members of the staffs af public tives, mayors, gavernars, and They have provided important politi managerial, and scientifIc leadershi agencies of government that have pI increasingly important rales.in natia life, fram the sanitary re-valutian<:¡ the 19th century to. the preverttionrp HIVI AIDS and the control of tobacc use today. Although publiCpealth 0. cials come from a -varietyofba grounds and oversee agencies o.f size and camposition, there are P sophical themes that describe and defi the commonality of their work. themes are captured metaphorical 3 celebrated figures: Don Quix. Machiavelli, and Robin Hood. By the public health o.fficial functions determined idealist (Don. Quixo.t cunning po.litical strategist (Ma avelli), and an agent whoredistri resources fro.m tile wealthier se of society to. the less well o.ff ( Hoad.) An 3 personae areimpo but, it is argued, Robin HoodÌs the endangered. (Am J PublicHealth. 90:702-706) 702 American Journal of Public Fitzhugh Mullan, MD Science and palitics came face to. face in the practice af public health. Public health practitianers, whether cammissianers af pub- lic health departments ar prògram staff, are assigned the task af putting the praducts af scientific discavery to. work far the papula- tian as a whale. This they do. nat in a labara- tary but in the public arena-a damain gav- erned by palitical farces and paliticians whase agendas are larger and more variable than thase afthe public health warker. Edwin Chadwick himself, the principal architect af British public health in the 19th century, discavered this when his energetic wark as a cammissianer af the General Baard af Health led to. its dissolutian by Parliament in 1854, a mere 6 years after it was inaugu- rated.1 Althaugh Chadwick's American can- temporary, Lemuel Shattuck, published his Report of the Sanitary Commission ofMass- achusetts in 1850, it was 19 years later (and after Shattuck's death) that his proposal for a health department in the state af Massachu- setts was enacted? These 19th-century leaders, and many who. warked with and after them, succeeded in caupling the grawing understanding af science-particularly bacterialagy, ar "san- itary science"-ta the engine af gavern- ment to. create the public health mavement. Althaugh born af government, this mave- ment so.ught to disencumber itself fram patranage and the venality of paliticians and the political pracess. Early leaders af state and municipal baards af health included social refarmers, paliticians, and physicians, and progress in sanitation was aften aff- set by carruptian and scandal. These baards facused an issues such as sewage and waste remaval, vaccinatian, and the testing af milk to ensure child health.3 In April 1872, Drs Stephen Smith and Elisha Harris of New Yark canvened a small graup o.f their calleagues to. explare the for- matian of an organizatian in what is the first documented professianal meeting af health afficers. At a larger meeting an September 12 af that year, the American Public Health Assaciatian was faunded a seminal mament in the establishment af public health as a damain af prafessianal practice. From that paint an, the American Public Health Associ- atian was a strang supparter af the farmatian afbaards afhealth and the professianalizatian af public health leadership.4 Mast af the early baards af health func- tianed as advisary badies, with little pawer to make changes in the face af competing inter- ests. Hawever, revalutianary discaveries made during the latter years af the 19th cen- tury, by Pasteur, Kach, and athers, led to. innovatians in areas such as the praductio.n af diphtheria antitax in and the cantrol af tuber- culosis, giving health afficials increasing credibility and authority. By the early years af the 20th century formal health departments had emerged as the agencies af public health, mast headed by physicians and staffed by sanitary engineers, bacterialogists, chemists, and trained inspectars. Their enterprises mul- tiplied rapidly, encompassing cantagiaus dis- ease cantrol, fa ad inspectian, plumbing, schoal health, child health, the licensing af physicians and midwives, and campaigns against specific canditions such as "sacial evil" (prostitutian).5 Public health in this epach gained an element of palice pawer and enfarcement that represented a degree of independence far public health officials that had not existed previously. It is difficult to. measure this degree af independence campa red with that af the current epach, but many important early leaders-such as Gearge Whipple af Massachusetts, Charles Chapin af Rhode The author is with Health Affairs, Bethesda, Md. Requests for reprints should be sent to Fitzhugh Mullan, MD, Health Affairs, 7500 Old Georgetown Rei, Suite 600, Bethesda, MD 20814 (e-mail: fmullan@projhope.org). This article was accepted January 22, 2000. May 2000, Vol. 90, No.5 . .... ,_..'" ~..þ. "'~~" .' Island, Victor Vaughn of Michigan, John Hurty of Indiana, and Oscar Dowling of Louisiana-held office for tàr longer than officials of today and provided significant public health leadership at the state and national levels.ó Perhaps the most influential health official of this epoch was Hermann Biggs, who served as health commissioner of New York City and then New York State for almost 40 years. His tenure spanned the turn of the century, and he played a leadership role in tuberculosis control, use of diphtheria anti- toxin, development of community health cen- ters, and administrative refonn.7 The Public Health Official in the 20th Century The Progressive movement of the first years of the 20th century gave Biggs and his refonnist colleagues an enonnous boost. The movement focused attention on issues such as poverty, child labor, maternal and child health, and social insurance. S Political Pro- gressivism melded scientific efficiency with moral compassion, creating an ideal environ- ment for the growth of public health. Although a number of cities on the eastern seaboard had health boards beginning in the early 19th century, and Massachusetts estab- lished the first state health department in 1869, it was the final years of the 19th century and the first decades of the 20th that saw state and local health departments spread across the country and the role of the health official in public litè become more important. Two very important developments for the public health movement took place in the second decade of the 20th century. The first was the enactment oflegislation in 19 I 2 that changed the name of the Public Health and Marine Hospital Service to, simply, the Public Health Service. It also added to the mission of the newly named agency the investigation of "the diseases of man and propagation and spread thereof, including sanitation and sewage and the pollution either directly or indirectly of the navigable streams and lakes of the United States.',9 The mission of the Public Health Service, which had previously been limited to quarantine, medical research, and the care of merchant sailors, was dramati- cally expanded creating a corps of federal public health officials who would serve as allies of state and local health officials working on local health, sanitation, and envi- ronmental problems. Indeed in the years following the passage of this legislation Public Health Service personnel tackled multiple problems of rural sanitation and health, including hookwonn, trachoma, and pellagra. 10 May 2000, Vol. 90, NO.5 The second portentous happening of this period tl1r public health practice was the advent of county health departments-a development that would ultimately create the largest cadre of public health officials in the United States. The suburbanization of metro- politan areas provided the impetus for the fonnation of the first county health agencies, which occurred in 1908 in Jefferson County, Kentucky, where Louisville is located and in 1911 in Guilford Countv, North Carolina, where Greensboro is lo~ated. 11 In 191 I a typhoid epidemic in Yakima, Washington, led the Public Health Service to dispatch Dr Leslie Lumsden, who, working with the state health department and local officials, performed a sanitary survey of the county. That survey led to the appointment of a full- time Yakima County health officer and estab- lished a pattern of Public Health Service locality surveys that catalyzed the fonnation of many county health departments. 12 Federal grants-in-aid to state and local public health departments began, cautiously, with the Sheppard-To'.'.TIer Act of 1921, which provided support to child health programs through state health departments.13 Congress killed the program in 1929 by denying it fì.md- ing, but the Sheppard-Towner Act proved to be a precursor to Title V of the Social Security Act of 1935, which has fueled the national Maternal and Child Health program through state and local health departments since that time. Title VI of the Social Security Act pro- vided the first program of grants-in-aid to state health departments for general public health purposes. This funding, coupled with Depression-driven programs such as the Works Progress Administration and the Public Works Administration, built a financial base under health departments that supported health surveys, new construction, and hiring of new personnel. 14 These developments armed public health officials with increased resources and larger constituencies, but they also made the work more complex and more political. World War II and its aftennath saw major changes in both health science and the role of public health agencies. Prewar sanitary suc- cesses against infectious diseases, combined with the advent of antibiotics and the polio vaccine after the war, decreased the focus of health agencies and the public on contagious illnesses. Mental, occupational, and environ- rnental health became the domain of health departments in a world dominated by the rapid growth of hospitals tinanced by the HilI-Bur- ton program, private health insurance, and medical research fì.mded through the National Institutes of Health. The administration of public health functions at the state and local level varied considerably from area to area, but Public Health Then and Now as mental, occupational, and environmental health issues were joined in the mid-1960s by Medicaid (in some states), the situation called tor public health officials with an increasing range of management and political skills. From the 1960s on, federal agencies funded augmented levels of state and local health department activity---often with state matching-fund requirements-in areas such as maternal and child health, nutrition, immu- nization, control of sexually transmitted dis- eases, and health planning. Prevention and health education were increasingly important themes in public health work in areas such as tobacco use, seat-belt use, injury prevention, and gun control. Perhaps the most unexpected aspect of the life of the public health official in recent years has been the resurgence of infectious disease. HIV/AIDS is the most prominent of the new infections, but the emergence of Legionnaire disease, hantavirus infections, toxic shock syndrome, viral hem- orrhagic fevers, and multidrug-resistant tuber- culosis in today's mobile and heavily popu- lated world has recommissioned the contemporary health officer as a soldier in the war against infectious disease. Throughout the late 1930s and I 940s, the idea of national health insurance was hotly debated. Public health officials often found themselves in difficult positions, caught between their desire to serve the sick and the poor and the American Medical Association's aggressive opposition to any national health insurance program. 15 The legislative campaign eventually faltered, but the national debate continued, resulting ultimately in the passage of the Medicare and Medicaid programs in 1965. Although a number of the programs enacted in the 1960s to provide health services to disadvantaged populations (e.g., the Com- munity and Migrant Health Center program and the National Health Service Corps) bypassed public health agencies, with federal grants given directly to communities,16 a devo- lutionary emphasis in Washington and the growing prominence of state governments have put state and local health agencies back in the middle of the debate about health care for the increasingly large population of uninsured Americans. The Multiple Roles of the Public Health Official In 1945 the great public health scholar and philosopher C.-E. A. Winslow assumed the editorship of the American Journal of Public Health, a position he would hold for a decade. He wrote: In the half of the century yet to come, the health officer must not be solely interested American Journal of Public Health 703 , , I !" \ . \ run.'" I.I.~al"u .. ..._.. _n_ in syphilis. tuberculosis. or even heart disease and cancer. He must more and more concern himself with nutrition [and] housin~. . He should lead in the elimination of substandard dwellings and participate actively in the planning for slum clearance. urban development and low-rent housin~. fk must concern himself with the livin!! -wa!!e and the provision of a due meas~re o{ social security which is essential to both physiological ~nd psychological health. In other words. public health which in its earliest days was an engineering science and has now become also a medical science must ex~~nd until it is. in addition. a social science.' I ¡ \ ¡ ! I; 'j Winslow envisioned the health officer as someone who would take on not only the problems of ill health in the population but also the social circumstances that generate ill health. Undoubtedly. Winslow's vision will resonate with many individuals who took up the mantle of public health practice in the latter part of the 20th century. It is an ambitious and idealistic vision. Half a century later, how does life in public health practice comport with the challenge laid down by Winslow? What are the principles and challenges that face the public health official of today? In the domain of public health at the out- set of the 21 st century, the stakes are very often high, and the life of a public health offi- cial is complex. He or she deals with some of society's toughest issues, including HIV / AIDS, environmental quality, abortion, addic- tion, and homelessness. Medicaid and Medicare, in particular, are big-ticket budget items, as are state-nul institutions and govern- ment-sponsored community health and mental health centers. Even nonbudgetary health issues, such as tobacco policy and nursing home standards, involve large, politically orga- nized industries. Needle exchange programs and physician-assisted suicide touch sensitive public nerves. Inevitably, public health prac- tice becomes involved in the politics of the time and place, and public health practitioners are, perforce, political players. These, of course, are issues that many others in our society engage as well. Public health officials, however, do not have the lati- tude of elected officials, who tackle these questions from their own political perspec- tives, mindful. presumably, of the preferences of their constituencies. Public health officials do not enjoy the certainty of business man- agers, whose approach to these issues is gov- erned by market forces and technocratic imperatives. And public health officials, unlike clinicians, cannot base their decisions on biological science alone. The public health official, in fact, must be politician, manager, and clinician in varying degrees at all times. Not only does this require a broad range of abilities and multiple data- ;) 1 ¡ I j ¡ 704 American Journal of Public Health \ III '0·, , I I FIGURE 1-Picasso's depiction of Don Quixote de la Mancha, the naive but tenacious idealist, who was the creation of the Spanish writer Miguel Cervantes (1547-1616). Quixote's name lives on in the term "quixotic;' meaning impractical but principled in the pursuit of ideals. bases, but the proportion of each ofthese skills that the public health leader exercises at any given time depends entirely on the circum- stances. At the height of a legislative session, the public health official must be an adept politician, twisting arms and making prag- matic compromises with the best of them. Back at the office, he or she will be called on to make major management decisions about computer systems, labor relations, and risk management for departmental employees. Immunization strategies, HIV testing policy, and Pfiesteria outbreaks call on the public health official's clinical judgment and training. Although politics, management, and science make a heady brew and ensure that the job will never be dull, stepping regularly between these 3 walks of life can be awkward and haz- ardous-not to say fatiguing. Don Quixote, Machiavelli, and Robin Hood On a philosophical level, the challenge runs deeper. Many people enter the field of public health because it is a discipline that promises to give substance to their sense of altruism. As Winslow suggested, it is work that puts principle into action, that struggles - .... ,~.., _..._..,._...._~ FIGURE 2-Niccolo Machiavelli (1469-1527), Italian statesman and author, is best known for The Prince, a classic text on the practice of cunning and calculation in politics and public life. The designation "Machiavellian" is synonymous with deceit, expediency, and cunning. toward the ideal even as it deals with some of society's most intransigent problems and most entrenched interests. For people coming of age in the post-Sputnik era, a career in public health blends science, the civil rights movement, and the Peace Corps experience. While solid waste and substandard nursing homes are more likely than windmills to be public health workers' targets, there needs to be a little Don Quixote in all public health practitioners-Don Quixote, the unabashed, unapologetic. unflappable idealist, locked in on his mission, undaunted by the doubters and the halfhearted. But Don Quixote alone is not sufficient. The stakes are high, and the adversaries of public health have never heard of Don Quixote. Altruism does not motivate land- lords to conduct lead paint abatement pro- grams or restaurateurs to designate no-smok- ing areas in their establishments. Those who want to protect the quality of air and water invite altercations with some of society's largest and best-organized commercial inter- ests. Battling-let alone besting-such inter- ests requires cunning, daring, and dogged- ness in variable measures. Although issues such as these are sometimes joined in the courtroom, they are never matters for judicial review until laws have been passed proscrib- May 2000, Vol. 90, No.5 ....".._..,~. ~ -.,,-.. ,- ~'.,~ m~~ FIGURE 3-Robin Hood, the legendary hero of 12th-century England, made his reputation robbing the rich to help the poor. ing certain behaviors as threats to the public health. Therefore, the first rounds of public health advocacy are always fought in the leg- islative chambers, meaning that the public health official must be adept at generating the alliances of political interests and support that will put public health statutes on the books. The proverbial horse trades and smoke-filled rooms must be part of the beat of the successful public health official. In his 16th-century treatise The Prince. Machiavelli laid out for all time the rules of cunning and intrigue in the conduct of palace politics. Public health leaders who are ambi- tious for their programs would do well to read The Prince and carry a modicum of Machi- avelli's pragmatic cynicism with them as they put their ideals to work for the public good. May 2000, Vol. 90, No.5 ~ ,,_.~' .~,-,... Public health work spans the geo- graphic, social, and economic breadth of our society. Rich and poor, uptown and down- town, rural and urban, commercial and resi- dential-aIl rely on the purity of the drinking water that is monitored by public health pro- grams. Every citizen is affected by the quality of laboratories and nursing homes, as well as by the investigation of disease outbreaks. Historically, however, public health depart- ments have maintained a special relationship with society's poor and less fortunate citi- zens, serving as an instrument to carry out programs of social equity that provide the poor with services that other citizens are able to purchase on the open market. Much of the work of public health departments today involves the provision of services to the vul- nerable and the disadvantaged for example, maternal and child health services, sexually transmitted disease programs, and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The public health department is, there- fore. an instrument of economic redistribu- tion-a public agency that uses revenues gen- erated by that part of the population that pays taxes to provide services to citizens who very often do not. The public health official is, per- tòrce, an agent of and often a spokesperson for distributional justice. If public health programs are to be successful, they must draw funds trom the public treasury and spend them on individuals who may be perceived by many as undeserving, troublesome, or even criminal. These programs will treat addicts, alcoholics, homeless persons, children born out of wed- lock, and AIDS patients. These people are the clientele of the public health official, and to serve them well he or she must be prepared to assault the public purse on their behalf Part of the public health official's professional identity must be that of Robin Hood, taking trom the rich and giving to the poor, ambushing the public conscience and budget whenever possi- ble to provide better and more humane ser- vices to the poor. Without such a sense of mis- sion, a public health official runs the risk of becoming a warden and providing leadership impoverished of both fmance and spirit. The Public Health Official and the Executive Keeping Don Quixote, Machiavelli, and Robin Hood in mind will help steer the pub- lic health official through the difficult and fascinating course that he or she must travel. A fourth person who must be kept in mind is the elected executive (president, governor, mayor, or county executive) for whom the health official works. The elected public offi- cial is as close as America comes to royalty. Public executives are potentates pro tem, and although not all of them act that way. most have the authority to command not only political loyalty but personal fealty. Elected executives (in contrast to elected legislators) have the apparatus of government as their responsibility and at their disposal, and the public health official is a beneficiary as well as a captive of that authority. A public health official who is of one mind with the execu- tive will enjoy significant derivative power, but one whose person or program is out of tàvor with the executive will find that power greatly diminished and most likely will be out of a job before long. Being in league and in step with the executive is more than a matter of palace pro- tocol. It is a requirement for professional effectiveness. It is also an arena in which the public health official enjoys a potential advantage over other public administrators, because a smart executive will recognize the technical nature of many of the issues in the health portfolio and will defer to the judg- ment of the public health official in a way that he or she might not with appointees who are less clearly professionally grounded. The public health official will be called on to tangle with other members of the execu- tive's cabinet on issues of economic or social contention in which the health perspective dif- fers trom that of other interests-when to shut down a convention because of Legionnaire disease, how to promote safe sex, when to declare a water source unsafe because of chemical or infectious contaminants. These circumstances raise issues for public health officials that do, indeed, invite the cotU1Sel of Machiavelli. The need to remain faithful to sci- entific and objective criteria for action must coexist with the necessary deference to elected political power. A public health official rarely succeeds in publicly stepping over his chief executive in pursuit of a public health issue, as Surgeon General C. Everett Koop did with President Reagan in the case of AIDS. The more common task of the public health offi- cial, and it is a crucial one, is to educate and persuade the executive at every opportunity. At stake are issues of style as well as substance, and the effective official will compromise far more often on issues of style than on those of substance. Robin Hood at Risk Although Don Quixote and Machiavelli are alive and well in the ranks of public health officials, there is reason to be concerned that Robin Hood is at risk. The role of health departments in the redistribution of wealth . American Journal of Public Health 705 Public Health Then and :"iow has always been open to some debate in the ranks of public health practitioners. There have always been public health leaders who have argued that the provision of medical care diverts public health from its real pur- pose and takes money trom its coffers. Indi- viduals holding this philosophy argued against public health involvement in early etforts to pass a national health insurance plan and prevented the formation of a med- ical care section in the American Public Health Association until 1949. is The same sentiments were extant in the ranks of the US Public Health Service and were responsible for creating an environment in which Medicare and Medicaid, when enacted in 1965, were never candidates for inclusion in the Public Health Service. Those sentiments in the public health community, coupled with what is often an activist interest in medical care in the welfare community, are responsi- ble for the fact that Medicaid was linked leg- islatively to public assistance trom the outset and for the fact that the vast majority ofMed- icaid programs have always been run by state agencies other than the health department. Medicaid is the largest redistributional pro- gram in the health sphere, and, unhappily, in many instances the public health community has allowed the role of Robin Hood to be played by others. The Institute of Medicine's landmark 1988 publication The Future afPublic Health dealt judiciously with this issue. 19 That report declares that one of the 3 major functions of public health is "assurance," meaning that health departments should concern them- selves with making sure that services get delivered to disadvantaged citizens. While this is a statesmanlike accommodation to the varied reality of attitudes about the delivery of medical services by health agencies, it does allow a fair amount of latitude to those who are disinclined to see health services delivery as an essential public health function. Most recently there was President Clin- ton's failed health care reform initiative, which would have ensured that all Americans had a primary care provider available to deliver the full complement of preventive and curative services. Had such legislation been enacted, the need for health departments to 706 American 10urnal of Public Health playa role in health services delivery would have been greatly diminished. But this did not happen. Although Medicaid managed care requires the provision of full preventive and primary care services, it covers only a minority of poor and uninsured Americans- meaning that the role of public health agen- cies in the health care safety net will remain essential for the foreseeable future. These historical trends, along with the impact of the welfare reform law, immigra- tion policy, and the declining levels of tree care provided by hospitals, mean that Robin Hood is embattled. Machiavelli and Don Quixote can provide Robin Hood with some assistance, but public health officials need to continue to speak out on behalf of their poor and disadvantaged clients, for whom the celebrated "marketplace" pro- vides little and for whom publicly spon- sored programs are increasingly the only option. It is easy to look beyond the health care needs of the moment to a time in the future when universal coverage will finally come to the United States-when health departments will be able to focus on assess- ment, policy development, and assurance. But that time is not now. It is hard to be certain, of course, but it seems likely that our forebears in public health-the strategists Edwin Chadwick and Lemuel Shattuck, the quintessential practitioner Hermann Biggs, the scholar and historian C.-E. A. Winslow, and the founder of the American Public Health Association, Stephen Smith-would share these apprehensions about the state of our system as we enter the 21 st century, and that they would call on the Robin Hood in today's public health leaders to be active and vigilant. ., Acknowledgment This article is based on a paper presented at the Presi- dent-Elect Session, American Public Health Associa- tion meeting, Indianapolis, Ind, November 10, 1997. Endnotes I. George Rosen, A History of Public Health (New York, NY: MD Publications Inc, 1958). 197-228. 2. Lemuel Shattuck, Report of the Sanitary Com- mission of Massachusetts (1850; reprint, Cam- bridge. Mass: Harvard University Press, 1948). 3. The following review of the history of publIc health departments in the United States draws trom Rosen, 294-496; 10hn Duffy, The Sanitar- ialls: A History o.f"Public Health (Urbana and ChicJllo: University of Illinois Press, 1990 I. 126-3 ì 6: and Paul Starr, The Social Transf;,r- mation o(American Medicine (New York, NY: Basic Books, (982), 180-197. 4. Dutfv, 130, 148. 5. Starr: 184-189; Duffy, 143,205-206. 6. Duffy. 222. .. Cha;les-Edward Avery Winslow, The Life oj Hamanll Biggs (Philadelphia, Pa: Lea & Febiger, 1929). 8. Commentaries by 3 important public health practitioners from the first quarter of the 20th century-B. S. Warren and Edgar Syden- stricker. "The Relation of Wages to the Public Health." and C.-E. A. Winslow, "Public Health at the Crossroads"-have been reprinted in the American Journal of Public Health 89 (19991: 1641-1648. 9. Bess Furman, A Profile of the United States Public Health Service. 1789-1948 (Washing- ton, DC: US Department of Health, Education. and Welfare, 1973),286-287. 10. Fitzhugh Mullan, Plagues and Politics: The Story olthe Ullited States Public Health Sen:ice (New York, NY: Basic Books, 1989),58-70. II. Duffy, 232. 12. Ralph C. Williams, Tlte United States Public Health Service. 1798-1950 (Washington, DC: The Commissioned Officer Association of the United States Public Health Service. (951), 141,337-339. 13. Rosen, 363-364. 14. Duffy, 258-261. 15. Starr, 280-286; Duffy, 275-277. 16. Fitzhugh Mullan, "The National Health Service Corps and Health Personnel Innovations: Beyond Poorhouse Medicine," in Reforming Medicine: Lessons of the Last Quarter Century. ed. Victor Side! and Ruth Sidel (New York, \JY: Pantheon, 1984), 176-200. 17. C.-E. A. Winslow, quoted by Milton Terris in the introduction to the reprint edition of Winslow, The Evolutioll and Significance of" the Modern Public Health Campaign (1923: reprint, New Haven, Conn: Yale University Press, 1984), x. 18. A. Viseltear, "Emergence of the Medical Care Section of the American Public Health Associa- tion, 1926-1948," American Journal of Public Health 63 (1972): 986-1007. 19. Institute of Medicine, The Future of Public Health (Washington, DC: National Academy Press, 1988). May 2000, Vol. 90, No.5 "~'~'.·""''1''~''O~~.''''''''W'''''''~'·''''-'''· 'T'~""-" """"."",,1'11" .......r '-;>', ...~ ". ,¡~...,;:-'f.~, .>TI" .~"'~ ',. "V..... Juelanne Dalzell JEFFERSON COUNTY PROSECUTING ATTORNEY Courthouse - P.O. Box 1220 Port Townsend, Washington 98368 Telephone (360) 385-9180 FAX (360) 385-0073 Jill Landes, Deputy Prosecutor Michael Haas, Deputy Prosecutor Theodore M. Cropley, Deputy Prosecutor David W. Alvarez, Deputy Prosecutor To: From: Re: Date: Larry Fay, Health & Human Services David Alvarez, Deputy P A, Civil Division Board of Health and ballot propositions April 24, 2000 Issue: What limits, if any, exist that would limit the ability of the Board of Health to collectively take a stand (for or against) with respect to any particular ballot initiative? Analysis: The Board of Health can collectively state a position regarding a ballot initiative as long as certain procedural niceties are satisfied. The regular notice of an upcoming meeting provided for any Board of Health meeting must list as an agenda item the possibility that the Board may approve a motion that would express its approval/disapproval of a ballot initiative. The meeting must provide opportunity for public AND Board member comment both for and against the position that Board intends to take. If those requirements are met, then nothing blocks the Board from taking a position regarding a ballot initiative. See RCW 42.17.130, portions of which are below. RCW 42.17.130 Forbids use of public office or agency facilities in campaigns. No elective official nor any employee of his office nor any person appointed to or employed by any public office or agency may use or authorize the use of any of the facilities of a public office or agency, directly or indirectly, for the purpose of assisting a campaign for election of any person to any office or for the promotion of or opposition to any ballot proposition.................. PROVIDED, That the foregoing provisions of this section shall not apply to the following activities: -- (1) Action taken at an open public meeting by members of an elected legislative body to express a collective decision, or to actually vote upon a motion, proposal, resolution, order, or ordinance, or to support or oppose a ballot proposition so long as (a) any required notice of the meeting includes the title and number of the ballot proposition, and (b) members of the legislative body or members of the public are afforded an approximately equal opportunity for the expression of an opposing view; ........ ~. Report for Jefferson County Critical Access Project CURRENT SITUATION REPORT Factors Affecting Access to Health Care in East Jefferson County, Washington Prepared by: Larry Thompson Kris Locke November 29, 1999 I. Introduction: the Area Jefferson County is situated on the Olympic Peninsula in Northwest Washington. Overall, it is the 18th largest of Washington's 39 counties. This assessment primarHy concerns the eastern part of the county-the area included in Jefferson County Hospital District #2. As a result, many data are adjusted to exclude the roughly 963 people residing on the pacific slopes of the Olympics in Jefferson County. District #2 encompasses the Quimper peninsula, where most of the population in the area can be found on the eastern slopes of the Olympics along the Hood canal. Roughly one half of the area's people live in the Port Townsend area zip codes (13,182 in 1999). The vast majority of the area's medical resources are located in Port Townsend near the hospital at the north end of the service area. About 10 miles to the south is the Tri-Area, consisting of three unincorporated communities. These are Chimacum, lrondale, and Port Hadlock and between them they have about 6,158 residents. Continuing south, at a distance of 25 miles from Port Townsend, is the Port Ludlow area with 2,709 residents. This planned community is resort, recreation, and tourism oriented. Along the Hood Canal, in the southern part of the district, are the communities of Quilcene (1,844) and Brinnon (1,087). From Port Townsend to Quilcene is about 25 miles and the distance to Brinnon is 37 miles. In recent years these areas have attracted retirees seeking rural living in the scenic area between the mountains and the Hood Canal. While the overall population density of Jefferson County is one of the least densely populated parts of the state, the East Jefferson area has a population density very close to the overall state average (86.5). 1 In addition to the medical care services provided within the East Jefferson area, services are available in Sequim (31 miles to the west) and at Port Angeles (48 miles). Located in Port Angeles is a significant concentration of consulting specialists as well as the Olympic Memorial Hospital-a Group 1 (rural) facility with roughly three times as many yearly admissions as Jefferson General. \lVhile some residents in the southern parts of the Quimper Peninsula and around Discovery Bay travel to Sequim for primary care, historic referral patterns have been to the east-to the Seattle area and Bremerton/ Silverdale areas. Tertiary and some secondary care patterns have long been established to Virginia Mason, Harborview, and University Hospitals in Seattle (50 miles including a ferry ride). More recently, growth of medical services and shopping in the Silverdale area (39 miles) have attracted Jefferson residents. Additionally, the large concentration of consulting specialists in the Bremerton area (49 miles), including a number who round to Port Townsend, have been in factor in the use of Harrison Memorial Hospital. Construction of a new facility near more accessible Silverdale transportation routes should accelerate the draw of Jefferson residents to Kitsap-based providers. This facility which will provide maternal and child health inpatient services and a wide variety of outpatient services, is scheduled for completion in January 2000. In Washington State 29 counties, or about three-fourths of all counties, are defined as rural. For purposes of the WashinQton State Rural Health Plan, counties are further classified into three tiers depending upon the degree of isolation of the county's residents from health delivery sites. Jefferson was placed in the middle of these three tiers-defined as Remote Rural. II. The PeopJe In 1999, the estimated total population of the East Jefferson area is 25,600. This was an increase of 30.4% over 1990 making it the 2nd fastest (in percentage terms) growing county in the State. The 1 O-year growth rate, 6,800 people this decade, equates to a growth in need for physicians of 4-6 primary care physicians and another 6-7 consultants. If the rate of growth were to continuE~ at this pace the area would reach 34,200 people by 2010. Despite this relatively rapid population growth, Jefferson County is likely to remain defined as a rural area for the foreseeable future for health planning and health policy purposes. The chart on the following page shows the rate of population growth from 19'70 projected through 2010. There is a long-term consistent pattern of growth ratøs far exceeding those of the State as a whole. The East Jefferson area will likely continue to experience strong growth due to the attractiveness of small town lifestyles, ample recreational opportunities, and easy access to urban centers. Lack of job growth is the primary inhibiting factor and the also greatly shapes the age distribution of in-migrants. 2 Rate of Population Growth: Jefferson County Compared to Washington State 600% 50.0% -+- % change Jefferson County 2 40 0% ra ~ .:: 30.0% 3: o 0> 20.0(;;0 ._~ ~ . . 41- % change Washington State 10.0% . ~---_._._--,----.-- 0.00/0'" .-.---.--.--------.--- ----------- 1980 1990 1999 2010 The chart below displays Jefferson County's age distribution in 1990 and the projection for 2000. vVhile there is growth in all major age cohorts. the most rapid growth, by far, is occurring in the 45-64 year old age group-the "baby-boomers". Comparing Jefferson's age distribution to the State as a whole reveals a relatively large proportion of elderly residing in Jefferson County. For example, in 1990 11. ï% of the State's residents were over 65 but fully 20. ï% were over 65 in Jefferson County. 1990-2000 CHANGE IN AGE DISTRIBUTION: JEFFERSON COUNTY 8000 2000 SÐOO 1000 0-19 20-44 45-64 65+ EJefferson_~~unt¥....!.~~Q_:I Jefferson Count¥ 200Q.. 3 This high percentage of over 65 residents makes the county one of the top 5 counties in terms of proportion of people over 65. Interestingly, the percenta~;;Je of elderly in Jefferson County declined slightly from 1990 to the 1999 (to 19.7'%). It appears that the relatively rapid growth in the 45-64 age group is the key fàctor and this appears explained by a combination of "aging in place" (the natural aging of this age group) plus disproportionate in-migration of younger retirees. Using census definitions, it is possible to separately identify the "rural" (non-Port Townsend) parts of the county. Residents of the these "rural" parts of the county are somewhat more likely to be over 65 and more likely to have a family income below the Federal Poverty Level. Only 2.6% of these residents are involved in farming compared to a statewide percentage of 5.8% for all rural areas of the State. Importantly, these differences between the "rural" parts of East Jefferson and the residents of the Port Townsend area are probably not sufficient to warrant separate planning and program development activity. Population changes occur as a result of births, deaths, and migration. For the State as a whole, about 40% of its population increase results from an excess of births over deaths (natural increase). The other 60%, then, results from net in- migration. Jefferson County's pattern is strikingly different, showing a negative natural growth (excess of deaths over births) and all growth coming from in- migration. Compenents of Population Change Jefferson Co, 1980-1997 1600 ill Natural Increase o Migration o -'---"'-""-~-'-----'----'-------------- 1400 1200 -..--..-.----,.-.-.-----....------ 1000 800 -~------~--- --- 600 400 200 -200 1980/81 1982/83 1984/85 1986/87 1988189 1990/91 1992/93 1994/95 1996/97 4 This observation is potentially significant for health services in several regards. First, demand for labor and delivery services is relatively low. Secondly, many of the in-migrants will have established care seeking patterns, habits, and expectations prior to coming to the county. Most of these new residents havè come to the area from urban locations. Many will even have existing provider relationships, which they may be reluctant to break. 95% of Jefferson County residents identify themselves as white. This contrasts to 89% for the State as a whole. Locally, the largest minority group is Native Americans at 3 percent, followed by small numbers of blacks and Asians. It is also common to categorize by ethnic background. In contrast to the statewide percentage of 4.4% Hispanic, 1 % of Jefferson residents identify as Hispanic. Socioeconomic Status Low income, unemployment, lack of education and other socioeconomic factors are often associated with health status problems. For example the 1998 Washington State Population Survey found that "children below poverty level are reported to have a 90 percent rate of good health while the rate is almost 100 percent for children at the highest income leveL" "The health disparity between low income and high income is most striking among non-elderly adults, where only 71 percent of those below poverty have good health, compared to 96 percent of those at the highest income levels". Poverty. For the county as a whole, 13.5% of the population had incomes of less than 100% of the 1990 poverty level. This is a somewhat greater proportion than for the State (10.9%) but less than the average for Washington rural areas (15.1 %). Over time, rates of poverty in East Jefferson have been increasing at a significantly slower rate than for rural areas, the State as a whole, or the Nation. In 1995, 8.2% of the county's population participated in the Food Stamp program compared to a statewide average of 8.9% Income. Typical of areas with its kind of employment profile, Jefferson County's personal income has consistently been less than national and state averages. At $27,362, median household income in 1994 lagged the State average by 13 percent. The local economy is disproportionately based on resource industries, services, small business, and transfer payments-all of which leads to below average household incomes. A striking phenomenon is that nearly 50% of local personal income is derived from transfer payments and investments, the second highest proportion in the State. Unemployment While it is likely that the Basic Health Plan mitigates against this phenomenon, persons in the work force who are self-employed and unemployed tend to have less access to health insurance and therefore to medical care. In recent years the local unemployment rate has closely tracked the movement of the State's rate at levels 1 %-2% higher. 5 Education. The county residents, on average, are well educated relative to other rural communities. Both high school graduation rates and percentages with college degrees meet or exceed statewide averages. There are four school districts in East Jefferson and some local access to higher education through Peninsula College. III. The Economy The Local Wage Economy For a number of reasons, knowledge of the local economy is important for health planning purposes. Perhaps most importantly, access to health care is in large part driven by each family's employment status. In a macro sense, the adequacy of local funding for direct health services is highly related to the mix of employer- types in the area and conversely, by the mix of government sponsorship among those who are not in the workforce. Beyond its effect on the health insurance system, the economy also influences, to varying degrees, income and education, injuries and other occupational illness, and environmental conditions affecting health status. It is important to note that by 1997, a minority (only 47%), of total personal income in the county was derived from employment. This percentage has been decreasing over time. For example, in 1980, 55% of personal income came from employment. It is further estimated that about 17% of total earned income derives from employment with firms outside of Jefferson County. Said another way, only 39% of total personal income is generated by the local economy. For health planning purposes, this means that the commercial insurance sector is relatively small, dependence on transfer source entitlement (Medicare, Medicaid, and BHP) is relatively large, and a good portion of the already small commercial market is actually sold outside of the county, reducing local provider leverage. The remaining part of this section now focuses on that local wage economy (39% of total personal income). While natural resources and value added processing (typical of rural Washington economies) continue to provide the base for the local economy, recent years have brought a growing diversity. According to the local Economic Development Council: "Small business has been the engine of recent growth. There are over 2,300 small businesses in the county and over 250 new firms have staried in each of the last five years. Small businesses locate here for several reasons. First, and perhaps foremost, is the rural character with urban amenities offered by a Jefferson County location. Quality of life issues .are paramount. Secondly, Jefferson County's proximity to large urban markets has attracted professional service firms and small manufacturers." 6 The area's small business growth has fueled expansion in the services and retail trade sectors of the economy. This is also inter-related with a very strong tourism base in the economy. For health planning purposes this translates to large numbers of jobs in relatively low-paying sectors and with small employers.:..-the kind of employment which disproportionately offers reduced or no health care benefit. In addition to tourism, trade and services, and resource-based industries, the government sector is also important with its 26% of total employment and above average wages and benefits. The list below shows major East Jefferson employers and number of employees: Port Townsend Paper Corporation 420 Jefferson County 322 Jefferson General Hospital 294 Port Townsend School District #50 175 Chimacum School District #49 158 Quality Food Centers (two locations) 1'40 City of Port Townsend 121 Safeway 107 U.S. Navy 65 Port Ludlow Resort Conference Center 50 Quilcene School District 42 U.S. Post Office 39 The Inn at Ludlow Bay 35 Port T ownsendl Jefferson Co. Leader 34 Enclume Design Products 32 Seton Construction 30 Thermionics Northwest 28 PugetPower 26 Coyote Found Candles 26 Coast Seafoods 22 Port of Port Townsend 21 Source: Economic Development Council of Jefferson County Transfer Payments Transfer payments derive from three sources-retirement including social security and pension plans, income maintenance or welfare programs, and unemployment insurance (UI). Together welfare and UI account for only 2% of total local personal income. Note however, that about 2% of local residents are unemployed at any point in time. These individuals will generally access COBRA benefits, sign up for the Basic Health Plan, or go without insurance. While only 1 % of personal income derives from welfare, in 1994 nearly 11 % of the Jefferson population accessed Medicaid as their health insurance source. All of this graphically demonstrates that Medicaid and BHP are far more important to the local medical economy than they are to the economy in general. Policy makers 7 have been more willing to direct tax dollars to medical care than to general income maintenance Fully 92% of transfer payments come from retirement sources. As the pie chart below shows retirement sources alone account fer about 22% of local personal income-about :he same as the percentage of Jefferson residents over 65. Most of these retirees. of ccurse. access Medicare. employer-based retirement plans, and supplemental insurance purchased by Individuals and families. \¡Vhile income related to retirement accounts for 22% of total personal income locally, it probably accounts fer '30-70% of the dollars spent on health care by Jefferson residents. This IS due. of course. to disproportionate use of services related to age. 1997 JEPFERSON COUNTY PERSONAL INCOME DISTRIBUTION BY SOURCE 8% 39%, 1% ::J investments :1 retirement :J income maintenance :J UI ]I earned income (local) :J earned income (not :ocal) _'."__ ...____..__~_...____.,____~ _'~_m_'"n -1 IV. Health Status Relatively few health status data specific to Jefferson County were available for this analysis. As a result only very broad measures of health care outcomes such as deaths. births. and leading causes of death are assessed here. Overall, Jefferson County residents do not appear to have radically different health status than residents cf the remainder of the State. The crude death rate for Jefferson residents is 30-40% higher than the State average and is increasing relative to the State. This is entirely due, however, to 8 the higher proportion of elderly in the county After adjusting for age, the county's death rate was lower than the States in 8 of the past 10 years. Small numbers render specific year-by-year changes difficult to interpret for the county. The. chart below shows the Jefferson adjusted death rate as compared to the State as a whole and all rural areas within the State It is interesting to note that the adjusted rate for all rural areas is consistently somewhat less than the State rate Jefferson County Age Adjusted Death Rate Compared to State and Rural Area Averages 550 450 - ~ ~___ _ a. .-:-_L~,:\__ --- ~--- - ----------- ........----- ~- - \ ,/ ...- -'---,,"- ~ \ ------w_ _--.....-.._ \ ---.-- - ---" -,~ --- \\ _/~ ~ /" / '-- / ". -------------- -- . ,,/------------ 500 400 - 350 300 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 ------_.~-----~----_._._----- -+- Jefferson County .... Rural Washington State .""vera_~ Of significance for health planning purposes, in an average year, about 35% of Jefferson residents who die, do so in a location outside of the county. This is a high proportion relative to urban areas and even relative to many rural areas. For example, the comparable percentage in Clallam County is 8%. Relative to the State as a whole, the place of death for Jefferson residents is also more likely to be at home and less likely to be in a hospital or nursing home. Detailed data describing place of death can be found in the appendices. Since hospitals tend to be associated with the beginning of life (births) and the end of life (deaths), the location of births and deaths will have a disproportionate influence on the demand for hospital services. Regarding leading causes of death, the following pie chart shows that 64% of Jefferson residents' deaths are related to just three causes-heart disease, cancer, and stroke. While this closely parallels other areas of the State, it nonetheless remains important for services planning both in the community and inpatient settings. Most causes of death closely track the statewide pattern. An exception to this is accidents where the local death rate is nearly twice the average. Since this is a long-term pattern, it points to accident prevention and 9 other public health measures as weil as to the development of trauma ser./ices. Across the State. all the counties with high rates of accidental death are classified as rural. Note however that some rural counties do experience average and below average death rates from accidents. Since at least 1980. birth rates in both the State and Jefferson COL.;nty have been falling. The rate of decline is relatively faster in Jefferson and the absolute birth rate is around 30% lower than 1998 Leading Causes of Death: Jefferson County 311 other causes 15°.·~, liver disease 1010 septicemIa 1·' ,. S·, ia heart disease 33% suicide 2~IO diabetes Z·' .. pneumonia and flu ~., "';',0 alzheimer's 2~\, COPD \. \ accidents \\. / 6~/o "<-.. '''" stroke~ ! 701 .. 24~/o the State average. Lacking more data it is not possible to determine to what extent this is related to lower fertility rates (fewer children per woman of childbearing age) and how much is simply a function of Jefferson's disproportionately elderly population. Typically 65-70% of children born to Jefferson residents were delivered in a county location. Comparable peroentages for other counties are as follows: Kitsap (84%), Mason (50%), Clallam (98%), Grays Harbor (66%), and Island (73%). Of those born in the county, the overwhelming percentage are delivered at Jefferson General. Each year. however, there are about 5-10 home births in the county. The combination of a low birth rate and an average (for rural areas) to high (relative to urban areas) outmigration for birthing services makes it more difficult to efficiently operate labor and delivery services locally. Maternal and Child Health outcomes for East Jefferson appear to be reasonably successful. For example, for 1997 and 1998 the percentages of low birth weight infants (less than 2500 grams) were comparable to the State as a whole, However, the two-year average of 5.65% did not meet the State's Year-2000 10 goal of less than 4.2% of infants having low birth weights. For the same two years an average of 85% of all pregnant women received prenatal care in the first trimester compared to only 75.3% statewide. This is a marker of relatively good access to medical care. On the other hand, the HEDIS standard is 95% receiving care in the first trimester and many organized, integrated delivery systems are achieving that level. v. The Health and Medical Care. System Physicians and Other Professional Providers Currently there are an estimated 15 primary care physicians (family practice and internal medicine) practicing in East Jefferson County. It is estimated that 1/3 of these physicians practice % time, yielding.13.75 full time practices. Mid-level primary care practitioners include 3 nurse practitioners and 2 physicians assistants. The Health Department also employs 3 nurse practitioners who provide clinics for sexually transmitted diseases and family planning services. A podiatrist also has a practice that employs an additional physicians assistant. East Jefferson County has an estimated 3 optometrists, 7 chiropractors, 2 naturopaths and 11 dentists. Determining the adequacy of physician capacity is a somewhat subjective judgement for a community to make. Various capacity standards could be used, however the age of the population will have an effect on need for services. For example, because the Jefferson County population is relatively "old", more physicians are probably needed. Smaller health systems also lack the elasticity of being able to absorb the need for short term provider coverage during illnesses, vacations, sabbaticals, practice turn-over or surges in patient demand. A survey of primary care provider capacity in East Jefferson County was done in October, 1998. After reviewing the survey it was found that 3 of the 18 physicians were not primary care (podiatry-full time, naturopath, orthopedics- "Y4 time). Also since the original survey, two primary care physicians have left practice (Blair, Gimbrere) and two have been added (G. Forbes, K. Forbes). Therefore, the current estimated primary care physician to population ratio is 1:1,862. Adding two more primary care physicians would bring the primary care physician to population ratio to 1: 1,625. The mid-range primary care ratio recommendation of the Council of Graduate Medical Education (COGME) is 1: 1,428. This suggests a potential for inadequate primary care capacity in East Jefferson County. Geographic Distribution of Providers Virtually all physicians practice in Port Townsend. Jefferson General Hospital operates a clinic in Quilcene, which is staffed by a nurse practitioner. 11 Specialty Distribution There are an additional 8 consultant or specialty physicians. Although the internal medicine physicians are likely provide consultation as well as primal)' care, they are discussed in the primary care section. Specialties are: general surgery; neurology; PT/OT; orthopedic; psychiatry; and, urology. There is 1 physician assistant working in the orthopedic practice. The adequacy of consultant or specialist physician supply is also a subjective determination. The availability of specialists not only improves local access to health care but can be a factor in keeping patients and health service revenue in Jefferson County. A high proportion of Jefferson County residents die outside the county (26.6%) compared to Clallam County (8.8%). The three leading causes of death among residents in 1998 were heart disease (91), cancer (64) and stroke (21). The benefit of recruiting specific specialties is a complicated question involving quality issues and the financial feasibility of hospital capacity to support services. More research could be done to look into potential volumes required for specific specialties. East Jefferson currently has an estimated specialist physician to population ratio of 1 :3,200. If an additional orthopedic surgeon is added the ratio will be 1 :2,844. The COGME mid-range recommended standard for specialty physician to population ration is 1 :1,053. If all East Jefferson County physicians are counted, the total physician (21.75) to population (25,600) ratio is 1:1,177. Adding two primary care physicians and one specialist will bring the physician to population ratio to 1: 1,034. The COGME mid-range recommended standard for total physician to population ratio is 1 :606. The COGME standard mid range physician distribution is 42% primary care physicians and 58% specialists. In East Jefferson County this distribution, if the internal medicine physicians are equally divided between primary care and specialty, is 63% primary care physicians and 37% specialists. Physician to Population Ratios COGME 1999 2000 mid- Jefferson Jefferson standard Primary Care Physician 1 : 1 ,862 1:1,625 1 : 1 ,428 Specialty Physician 1 :3,200 1 :2,844 1 : 1 ,053 Total Physician 1 : 1 ,177 1 :1,034 1:606 Health Care Facilities Within the geographic area of the East Jefferson District there are two medical care facilities of importance to this project. The first of these is Jefferson Gene!ral 12 Hospital. a community general hospital licensed for 42 beds currently operating 37 set up beds. The second relevant facility, also in Port Townsend, is the Kai Tai Care Center, which is licensed as a nursing home with 94 beds. Facilities outside of the District also playa major role in providing services to District residents. Jefferson General is a rural hospital meeting eligibility criteria for State Critical Access Hospital Designation. Generally speaking, this eligibility turns on distance, population, disproportionate share, and trauma system factors. Compared to the average of other eligible hospitals, Jefferson General is somewhat larger, has a higher average daily census (ADC), and is somevvhat less vulnerable financially. Demand for inpatient care at JGH has trended generally upward since at least 1990. During this time, the ADC has been in the 11-13 range. If present trends continue (see chart below) the ADC will increase to the 14-17 range by 2005, yielding an occupancy rate of 38% to 46% on the current number of set-up beds. While this occupancy is low compared to all \Nashington hospitals, it is in the higher end range of all rural hospitals. Growth in demand is being driven primarily by population growth rather than by market share, which has remained fairly stable over time. The population use rate had a pronounced decline in the early 1990s in line with statewide trends of new outpatient technology and the growth of managed care. In the latter half of the decade the use rate has stabilized. All of these factors in combination lead to the conclusion that JGH should not give up bed capacity as would be required for Critical Access designation. In fact. the area is relatively "under-bedded" as shown in the table below. If market share were to increase, the hospital could easily begin to experience staffing and capacity constraints. 13 FORECASTED ADC AT JEFFERSON GENERAL HOSPITAL USING 3 SETS OF ASSUMPTIONS 18.0 . 160 . 14.0 ,,- ---_.~--------_.._--~------._.._---_. --.-- ."--- -+- optimistic (original) forecast ___ mid range Forecast -û- most conservative forecast -Linear (most conservative forecast) -Linear (mid range forecastì -Unear (optimistic (original) forecast) --'---^-'--~-'---_._----~--_._--------~--_._--"-- 8.0 ~--~------------------ ------------------- ---- -- -------- -,,-- -----,,--------..- 6.0 ---- ----------~--- ---- - 40 .._------_._,--- ._.__._---,-~. 2.0------- .------ 00 :>~ '- " ,') ';. . 'i:> b ~ a:. 0. i:) , , ~J ':>. 'i:> ~J ~ ~v~ ~ ~ ~ ~'~ ~J ~ ~. ~v~ ~ ~ , ".;- V V ".;- '(- '(- '(- '(- ',- '!)' ""- '0,,'" '0,,'" '!)' 't' From a financial point of view, the hospital picture is more mixed. In 1997 the hospital had a negative operating margin of 1-% improving to a positive .62% in 1998. This compares to a statewide average of 1.85% (itself lower than desirable). However, using revenue from non-operating sources, JGH has hac! organization-wide positive margins in 1997 and 1998. This resulted in a 9.5% increase in total equity over the two-year period. As of year-end 1998. the balance sheet is healthy. All of these factors led to JGH NOT being designated by the State as one of the "financially vulnerable" rural hospitals. Despite the current financial picture, the hospital does remain susceptible to longer-run financial threats. A key factor in this regard is the relatively large (53% compared to 33% statewide) proportion of revenue coming from Medicare. This percenta~~e is among the highest in the State at a time when almost all observers are predicting a pronounced decline in the rate of increase in Medicare hospital revenues. On the other hand, JGH does have relatively low (23% compared to a state average of 31 %) overall contractual allowances) probably reflecting low 14 Financial data were unavailable. The facility does not have SNF capability or the ability to handle complex patients in lieu of hospitalization or as a 'step-down" from hospital care. The data below demonstrates the relative availability of facility capacity in East Jefferson. Set up hospital beds/1000 total population in East Jefferson 1.45 Set up hospital beds/1000 total population in Clallam County 2.01 Average hospital beds/1000 total population in rural Washington 2.67 Average hospital beds/1000 total population in 'Nashington State 2.09 Nursing home beds/1000 elderly in East Jefferson County 17.7 Nursing home beds/1 000 elderly in Washington State 42.9 Nursing home beds/1000 elderly in US 53.4 Patient Flow/ Patient Origin Patient Origin studies are useful in measuring a population's pattern of hospital use. 1998 data provided by the Washington State Hospital Association show that 58.1 % of all East Jefferson residents who were admitted to any hospital in 1998 were admitted to Jefferson General. While only 42.7% of hospital days incurred by District residents occurred at JGH, lengths of stay were longer at out of area facilities, which seems appropriate. The pie chart below shows which facilities hospitalized District residents. For example, 14% of all admits were at Harrison Memorial in Bremerton and 19% were at major Seattle hospitals. 1998 ADMISSIONS of EAST JEFFERSON RESIDENTS by HOSPITAL a":E==:=:RSON GENERAL .HA::¡~;SON \1EMORIAL t:lV¡R~'NIA ~11ASON OS'N::JiSH .:...i~~:''¡=RSITV OF WASH1NGTON iI¡.4.A~g:J,;{ViEW . . JlOi....~·,fP:C MEMORiAL C~.1ASCN '3ENERAL .OR'],;::) EN CE-S E.A TTL:;: .CH<:REW$ .~!-- ~-=_._,_-:-~~--------,--------_. 15 A look at the chart below reveals the kinds of serJices local residents leave the area to receive in other hospitals, ,A,pproximately 8-10% of all admits are for tertiarj services which JGH will probably never offer But another approximately 32% of admits are more discretionary reflecting patient choice. provider availability and, to a lesser extent. insurance coverage requirements, For example. 55% of all orthopedic surgery cases. 52% of all gynecology admits. and 31 % of all obstetrical cases (deliveries) occurred at out of area facilities in 1998, Note that these trends have been relatively stable for a number of years, suggesting that 1998 was a typical year 1998 MARKET SHARE by SERVICE , # ! , ¡ -., # ~ .,. o_.__....,.._¡ . '-8 .. . ____ ',,,. _...,...c._...~.,_~.._ . 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"''''..-~... -...,......~.,-rq~.. J~···,........~..,.,-"7\"='~n7~~..,..,.,...,""""- ~=- .~.... -.0.--:-.......... ..~. --,..... _... -~ . ~~~- .! '-.- -.-... .~ '-- ......, _.~..." ,.,.,.,...--.~;"';'""'..".". ..~-~.,., .' ..,.. .......=......,................,............". .~_.,.;¡ -.'-... ....-''',..._'.-.._..,....,..--,..,~...-._,............~.~... _--..~ - "'''''- ,. ""0::.-.-...:'''''::'''.. ~_ ,_,.,.,.,_...., .'.;;.<.:;.;.;:.!.. .'__.-"'.'. ..'~..,"',..."='.n..............r......""'~r'-n"...,-,-...........·r"L~'~~'......~.n...,_T.......""''''-.. '._"_"___~"-"_"'.." ··,..,-"-·t··.__. "~'''''.''''''''''~<~. ~.-ro"""'" ~....~~ ~ <I +t->-,. ... .. '_"""~'""''''''''_T"'''''<'''__''_''''~''''''''''''','''''''''''''''''..__';;-'''''~.:<o:~, ..,,~ ~-.... ..._.......;.,:..,_.;_... _iW- ,~;..;...::_"..... ~........;.;..;.. ~. ..~ .., '.' <.' ,__ ,." r" _ .,~ ._ .." .~--::.,,~~~~ ,. ....TT>-'UT.... ~......-;.~. . ._..... .'U..........'.'.rr'"<.n".__, .. ¡-.. . . ....- . -..,-.------. .... --~._,.z..-.. .."...~- ._.-..._._.... ._. _..._ .."_;.<..,.,¡"""":-...".,.~.....".".,.=_.t>--'~.",,~-'hX.;,,._..,......_~,:~~ ,¡....,"""'.. :>J ]"') .:,0 ~'i.) J.8 8% 5·J J% SO ;:;:J,~ 70 :% ;~G _>~~30JO~ -; CO J'~-Q 16 One of the important policy choices facing Jefferson residents is to define the appropriate range of inpatient and outpatient services. which should be locally available. Related to this question is the further development of the optimal regional referral system. Present evidence suggests that a relatively large proportion of hospital care is occurring out of the area. The extent to which the bulk of this is or is not appropriate is a choice point for further development of specialty care services in the east Jefferson area. VI. The Financial System for Medical Care The financial system for medical care can be viewed as occurring at three levels. The first of these levels, the payer level relates to the actual source of funding such as individuals, employers, and the public (taxpayers). Since the 1930s, a second !evel of financing-the health plan or carrier or intermediary level-has developed between the payers (funding sources) and the providers (delivery system). In Jefferson County, this intermediary level is less extensive than typically exists in the state or the country as a whole. The third level, where the services are actually provided, is, of course, the delivery system level, Payment Sources for East Jefferson Residents An estimated $81.2 million was spent by or on behalf of Jefferson residents for personal health care services in 1997. To put that number in perspective. that spending level constitutes an estimated 14.9% of the total local economy, undoubtedly one of the largest sectors of the East Jefferson economy. Where did the $81 + million come from? The pie chart below shows that just under half (44%) came from government sources with the Federal government putting in almost $4 for each state dollar. The remaining 56% came mainly from individuals and from private health insurance. Specifically. about 19 cents of every Jefferson health care dollar came from out-of-pocket expenditures by individuals. Another 32% of spending came through private health insurance. State-wide the proportional mix within private health insurance funding is 92% from employer sponsored insurance (half self-insured. the other half purchasing commercial plans) and 8% from individually purchased insurance plans. Because of the small size of Jefferson employers. it's unlikely that many self- Insure. 17 ';·~fferson ':ol1:1ty .3ourc~s of '-1~Jlth 3'js:em i'undinq ;~J~-=- J.'"':: ''''''"",;J "' '-', ). - ..:: ::: '\"?: . :''1 .:?:: ~,'] :: ~ )/, ,)~;1er :)(ivat·g :1S;J;",'30':= ;u~·jS 22'S -+ '¡'¡r:le a ~e!at!'iei/ siT.a!! çar: cr :re health care eeoncr.¡y. Irdi'¡!CLai and ;ar.¡I¡~j ir:::.'r:::;rro . .....Lr-~;::::::.ori '-\' ;rr'I"j;,...<L;.....i- ~.....:::, ~,""cr .:ro,~L·ort!'./ ;.....·~o-o,' :::. :::;-~'""1';::C: .. _.....l-t __ ,_......, \~ . _, ,..................,''-'1 ...J/ .;...... tl...4 C ,:, . :c:...... .......v~ : . oJ'-1 '-"I,'í,¡" ,I, .1 ;',-, ;_ ,,__ _\.....-1............... 'i/asrlrgtor S:3t9. Ai. :r.e :resent :irne.excect n a hanaTul cr cCL.r:ies. ,ts !Iterally !mpCSSicie to pL.rehase suer: coverage. Fer now. hcvì8'ler. East JeT7'ersen :-esicerLs '¡,¡re already have :ndividua¡ieaith :rsurareece¡;e:es. are gererally able :e cortinue it. Since '¡irtua!ly all of the iceal irciv!duai cO'jeraç;e s 'M:tter oy KP S. the sclvercy JT this nsurer, :ak.es en ;~reat :mcertaree for an estimated 1.:CCJr so indi'¡!duais covered c;/ irci'i!:L:a! :Jiars r:: -'jOr.....m........,· ;, ·"''''·1.....,..., - "'~....."'or;.·lnr.....Í"-'¡\/ mero ;rn.....o""........,· ...... 7~ - ::.....,;::. '.......:..:or-,-.,r ~u -oJ I! ~;,~ ....... ,1_ J '''d ;:, ;....·1 _~ ~ -' ;d:.~... :. ....., ¡ i'~ I '~C:L:" .'...) ..I ,::= \.-~......I.. vCi,....-I';:'\"'" ~ecica¡ 9C8r.CGY The table c.e!o\¡v sho\¡vs that aboLt t¡aif of :cca¡ r9S¡C~erts -:3'/2 commerciai :rSL:r3nCe jr: ccr:trast to an estirriated, 59¡~{) state'/vic.e. Jefferson County Estimated Distribution of Insurance Sponsorship: 1998 Insurance JeffersonCounty __~'/ashington State Spo nse~s~E________~ u m be~__ Pe~£~t _~_,~_u m ~~[__~____Ee rce~!_ Commercial 12368 48.SJá 3.354.32- ~;:J.U-J --------------- ~---- -~--~~._-~-_._-- Medicare 5.739 227=/J 733.593 12.9:~ -----_._~------ Medicaid 2.628 1 0.3YJ 750.270 -~ 32 >J ---------_._.._~ "---~-- Basic Health Plan 153J. 6.0% 219.661 3';:;; --..- ._--_._.~_.._-_.~~----~------------_._------~--_.._----_._'-~-'"--'-------'"---- Uninsured 3.188 12.5% 625.333 '1 ~ .0:,: -------------,------~.._-~_.._------_._~_._------_._--....-- ----------~-_.,-~-_.__.._--~_.._'-----_._-- Estimated Poeulation 25.5CO 5.S35.3CC ----. -------_._---~---~--------_.~_._--- Medicare. Medicaid. and Basic Heaith Plan enrollments are actuals as of .1;larch 1998. Commercial insurance is an update of the 199-1 Arthur Anderson study and:] 199ô HCA study 18 The large Medicare population, as would be expected considering the demographic data reviewed earlier, causes the bulk of the difference. Fully 23% of local residents have Medicare as their primary coverage. For the local medical economy as a whole nearly 1/3 of all health care revenues come from Medicare alone. For certain kinds of providers such as the hospital and many physicians, the proportion is even higher. East Jefferson residents are somewhat more likely to be uninsured or covered through the Basic Health Plan but are less likely to have Medicaid coverage. The relative dominance of government funding sources has many implications. For example. Medicare and Medicaid fee-for-service payments are heavily discounted thus reducing effective incomes for providers. Additionally, many argue that government funding sources reduce provider operating flexibility. In any event, it is clear that the total per capita flow of funds into East Jefferson is in the range of 5-15% less than it would be if the same demographic mix of people lived in Seattle or one of the State's urban areas. The result of less per capita funding is that local providers must be more efficient than their urban peers or lower provider incomes or fewer services per person will result (or both). For East Jefferson the evidence suggests (see Health and Medical Care System) that provider incomes are lower and that fewer services are available and uhlized. Health Insurance in East Jefferson Of the $81.2 million in local health care spending about 60% or $48.7 million is administered by one of several health plans operating in the county. Since the early 1990s, the health insurance industry has undergone a series of changes with major implications for the local delivery system. These changes include: · Increasing pressure from payers to control costs · Increasing shift from indemnity to managed care plans · From 1996-1999, most Washington insurers had negative operating margins which in turn led to: con so I idati on/mergers; withdrawal from the less attractive markets: less competition; increased difficulty in buying insurance in many places for many products: ultimately to higher prices. For roughly 40% of East Jefferson residents, no third party payer is in the picture-that is, the funding source directly pays the provider for care received. Most Medicare eligibles in the area currently have a direct relationship with Medicare (also they will nearly always have supplemental insurance as well). Other direct payment relationships include the uninsured (who either payout of pocket or receive charity care), about half of all Medicaid recipients and a few State employees (uniform Medical Plan). For the remaining 60%, the choices are relatively few. At least half of those in the health insurance system are covered by KPS. The next largest group is the self- insured and those covered by a wide variety of small market-share indemnity 19 plans. HMOs and other managed care plans have a relatively small market srlare of 14%. For the state as a whole, over 80% of insured residents are in some type of managed care plan. The 1990s push by government payers to convert enrollment to managed care has had some impact on Jefferson. All Basic Hei31th enrollees (1,500) and about half of Medicaid eligibles (1,200) are In managed care plans. Medicare managed care enrollment (332) is almost all placed with providers outside of the county as is the commercial HMO enrollment other than that sponsored through KPS. ESTIMATED 1998 FEE-FOR-SERVlCE & MANAGED CARE JEfFERSON COUNTY Uninsured Medicaid fee-far-service BHP fee-far-service Medicare fee-far-servICe Commercial fee-far-service & PPO Medicaid managed care BHP managed care Medicare managed care Commercial HMO TOTAL enrollment 3188 1448 o 5457 11728 1180 1534 332 ;õ40 25507 I2§:cent 12% 6% 0% 2'1% 46% 5% 6% 1% may be statutorily authorized comments includes self-insureds all KPS; KPS exit as of 11/1;99: CHPW to re¡;lace 11;1;99 99% "\ere KPS; CHPW to re place 11!1 ;99 87% are GHC and affiliates mostly PEBS: mainly KPS 'NIth some GHC. ;~egence, Heaith P!us 3~fJ 100% The reasons why there are few choices in the East Jefferson market are complex but the result is a vacuum which dampens (at least temporarily) demand for/access to medical care services. Additionally, the recent KPS financial difficulties have major implications for East Jefferson given the dominance of KPS in this market area. Uses of Health Care Dollars The third level of the medical care financing system is where the dollars are actually used to provide services. Aimost 89 cents of every dollar buys direct personal health care services. The remaining 11 %, spent out of county, buys research and construction and various forms of public and private (insurance;' administraHon. The table below displays estimated Jefferson County uses of health care dollars and the proportions of these spent inside and outside of the local economy. In 1997 an estimated 70-75% of personal health care spending for Jefferson residents occurred within the county. In particular, relatively large amounts of hospital and physician services were purchased in surrounding areas, 20 ----------,----- -.---- ------_..~-~-_._...._--,---~_._- -------.--.--.--------.-------.-,..- ..-.-.-.----.---...--..---.-. ---,....~_..--_._-_._--_._..._------- -....---- -.----.-. ~jsJ¡o Sçe[~c¡r~q fer Percent :=stimatec: of T~t31 .Jeíferscn:c. Scent ,r~ ,;\íT1ountSper't =xcenditures 2cenein9______ Res;cents ¡:cLfn'¡ ~~~cu;~t~___. Ji~~ th S~rJi~es an~ Supp¡i~s _2~9:~____§3~J43G9S.òº_ 3)·ô~~_-ª59a83.943A5~_ :::;~rscnal :-'ealth Care 3870~J 38: 233.359.95 71 ï'CS S58 243.387 76 Jefferson Count'! ~stimated iJses of Health Care Ss in 1997 ----------- '::stirnatec ;:)(31 ::stimatec ':-'osDitaí -:; are __ ,::::hysic:an Serlices Dental Ser;ices Other P;ofessionai Se'l/ces /-fome ,'-1ea/th Care Crugs ar:d Other ;\icn- CuraCIes i'h¡rsfrç;,crre Care Other ,=erscnal ,c.ieaith Care Vision ,=roducts and Cther Curacies Frcgrar;¡ ,":',cminlstraticn and \je[ Cost 'Jf Private f-<ealth :nsur"nce Government Public ""'eaith 34.3C/~ 331 a37,-1.21 '13 sa...FS -_.~~-----~---_.~---- 2COO'] 318.3:5.-423.40 ----..----.-..,.- 4.3ci:, $4.212.778.53 55% 55.037017 81 3.00'-: .32.747464.26 70 IJ~'S go.Co? 95.0% 95.:JC~) .~-- d·Pô .33.608 72~ 35 35.J~~ 3G.CS<J -.- ..... "'/ . 'J~ J 'ì "=/ '-. 'JQ Sã. gee .2j2. 79 32.38i .135.59 30.0~b 3952.-+54.28 31.190567.35 .... .~ J:.., ,...... ''-' 80.oJ';/) '-'Ï'),q .~~ - ":'-R. ..:.JL"-'-'...."".:J......,...." 5.GO~ 34,57910710 5.C~'Ó S:.5~i,1C5.34 Research and Construction 3 1 ?~ Total !-'ealth Care '::xcenditures In 3ehalf of Jefferson Resicents : Goes 'Estimate appears .'7U;;n Of total personal heaith cae excer:citures. abcut 39% Nere "cr hcscital services ar:d ar:cther 23'~{¡ ~or cr:ysiC'an ser'/!ces. Other large sec:crs 'Nere::rugs arc~cr- ...., 'ratio<=: 11 J/. , ~r''''¡ ,..., .,..~,,...,, ''-''''I'Y';::''''''''''''''' QO;"¡ C:oc ~n~r- ~el""\,¡ '-4~ ......._ : .,0 I .;:: ......, '1..,..;1 ":::11 ,~ ' :v¡ i'...... ,.....d¡ '...., .~ /0 J. v............. _I,C '. __ ILl'. ;~\ctÎv¡t¡es 3.3q<~ 33.022.21 0.:39 SO.O~/Ò .3êC.335.362.37 32.839046.40 3COo/() 39! ,5.32."' ..12.00 3ô.4'ie 313.1.92.559.02 312.321.499.88' 33.791.5C033 S4785.16ô.32 52.3~O,C91 :5 S7.3~7 '+13.15 35.5ê8_ , 9J..23"r 31,904908.55 S851.7'3.92 éS7!!¡IATéD CISTRI8UTiO~ Or 199ì JE¡:¡:=RSON COU~JTY PERSONAL HEALTH CARE EXPE~JCITURES '/:s,c~ =rcdt..;c:s -3r:c '::~~-=r :u!"'ab'-3s ~ ;)~ :~h ~r ,:::~rS;::"",;¿j1 ~-=,;:Uh ar.::. _ 0 "iu~s;~g "";;:"~e::J;,-;? ; 'b :r'.:gs ard ::~her . ¡cr.- ::;r3:::~~S 39% 11'J! , 0 ~::::-:a :-:~a:~h :are ....') ::ther ;:)rcfessJcnal Ser'::ces 5i)b Physician SerJices 23'& Centa¡ 3e......ices so¡, 21 TWELVE KEY FINDINGS 1. Services are heavily concentrated in the Port Townsend area in the far northeast part of the district. This is probably one factor in the relatively large out-migration of consumers to medical services in other counties. 2. Overall a large proportion of retirees, producing increased demand for services, compounds population growth. 3. The nature of the local economy presents major challenges for health care. The combination of increasing dominance of small employers and dominance of transfer payments in the economy translate to relatively low per capita reimbursement for medical services. This "underfinancing" of the medical sector in turn increases difficulty in attracting and retaining medical personnel and investment. 4. While problems of poverty, unemployment and other financial access issues affect a sizable proportion of local residents, the relative magnitude is not extreme and is manageable. 5. Locally, specific health status problems are generally not major issues. The exception to this is "accidental death' which has public health and trauma care implications. 6. Significant amounts of care are provided out of the area. This underscores the importance of making key policy choices regarding the future mix of local provided vs. regionalized medical care. Continued population growth in the area will continue to test the status quo. 7. Relative to urban areas and even to many rural areas, the area appears to have a significant undersupply of physicians. While this is an issue in regard to primary care there is also a major choice point on the horizon around whether, how much, and in what specialties to expand consultant care availability. 8. From the perspective of current demand, the choice to close down some acute care beds and to limit lengths of stay (Critical Access Rural Hospital considerations) would be very questionable. Considering the growing demand for services and the "crossroads" policy choices facing the area in regard to increasing availability of some services locally, it seems unwise to constrict hospital capacity and capability at this time. 9. The health insurance market in the area is very unstable. This presents a number of challenges. More residents will be financially unable to access care. With no competition. pressures on already strained provider incomes will be more Intense, working against desires to increase availability of services. More care will be controlled from out of the area continuing or exacerbating problems of leakage. Innovative opportunities to better align service delivery with financing in order to increase efficiency are hampered by the instability (but may also foster opportunity). 10 The current East Jefferson health insurance market is dominated by KPS. The weakening or collapse of this health plan will further de-stabilize !ocal services and will move control of the financing system further from local providers. 11. The local health care economy is heavily dependent on government funding sources. In the current political climate this presents many challenges both in managing for today and in planning for the future. 12 The local health care economy is relatively unaffected by managed care. While this may have positive aspects in regard to free access to services, it may also stifle development of some aspects of the delivery system. Consolidation of medical practices for increased efficiency, shift of care to the outpatient setting, and development of population-based approaches to chronic conditions lag the urban areas and even some rural parts of the State. ANTICIPATING THE FUTURE Nine Predictions to Anticipate and Plan for over the next five years.... The following predictions were written by Larry Thompson. Many were based on ideas from a monograph titled "Health Care Futures" which was written by Lance Heineccius. 1. There will be 4-5,000 more East Jefferson residents of which close to 1,000 will be retirees. Among other things, these newcomers will require four more physicians just to maintain the same level of access. 2. There will be continued turmoil in the health insurance industry and in the government sector in regard to health care. Reform will be incremental at best and counter-productive at worst. This vacuum of leadership will open opportunities for bold leadership but most will experience primarily frustration. 3. Although cost containment pressures will never completely let up, the period of 2000-2003 is likely to see renewed consumer health care per capita inflation in the range of 10% per year. While this will ease pressures on East Jefferson providers somewhat, provider incomes may only experience modest increases. Moreover, by about 2003-2005, counter pressures to contain inflation will again predominate. Providers who use the 2000-2003 period to "breathe easy" will be disadvantaged relative to those who continue to push for increased effectiveness and efficiency. 4. Physician frustrations will continue to build during this period. In East Jefferson, this could lead change in a number of different directions from disengagement to new forms of physician organization 5. Development of more extensive services in Silverdale and Sequim will increase consumer choice but will challenge the District to re-examine its role in a regional context. 6. The safety net of health care services is likely to fray but not unravel. As the economy cools and as policy makers are faced increasingly with eligibility vs. coverage trade-offs, East Jefferson is likely to experience an increase in the uninsured perhaps back to early 1990s levels (15-17%). Employers will also be under more bottom line pressure with impacts therefore on the employment-based insurance system. 7. Health care consumerism will continue to gradually expand resulting, among other outcomes, in increased demand for choice, information, and geographic access. The near term development of local health care information technology will have major implications for current District delivery system's ability to present itself as an attractive choice. 8 The tools for population-based chronic disease management will begin to mature coincident with the continued shift from acute to chronic disease emphasis in the delivery system. Linking into this movement will be challenging for under-resourced and fragmented delivery systems. 9. Inevitably, the East Jefferson physician delivery system will greatly expand over the next 5 years and will include a more robust mix of consultants. The District will face a choice point as to whether and how much to manage this change, In the broader environment, and even in many rural areas. more integrated physician networks are replacing solo and small group practices. EAST JEFFERSON IDEAL SYSTEM REPORT CARD HEAL TH SYSTEM ATTRIBUTES 1 AVAILABILITY OF CARE A BROAD SCOPE B NECESSARY C COORDINATED REGIONALLY D MINIMAL DUPLICATION E MAXIMAL MARKET SHARE 2 ACCESSIBILITY TO CARE A GEOGRAPHIC B AFFORDABLE TO CONSUMERS C EQUITY/ EQUALITY BY PAYMENT SOURCE D CULTURALLY ACCESSIBLE E ACCESSIBLE AT THE RIGHT TIME 3 QUALITY A TECHNICAL QUALITY B RESPONSIVE TO PATIENTS C INNOVATIVE D WELL COORDINATED E CONTINUITY OF CARE 4 FINANCIAL A EFFICIENT B HEALTHY BALANCE SHEETS C PAYMENT SYSTEM SUPPORTS OTHER GOALS SCORECARD GRADE KEY FAILING NEEDS LOTS OF WORK SOl SO PRETTY GOOD MIGHTY FINE report card CURRENT VALUES AND MISSION OF JEFFERSON GENERAL HOSPITAL Broad and noble purpose Assure appropriate health care services are available to support the health of the people of Eastern Jefferson County Well established values · Patient oriented · High quality services · Respect for all points of view · Healthy community through individual responsibility · Wise and prudent stewardship of resources Clear miss.ion A strong, coordinated, locally focused, quality health care system providing personalized service. · Strong financially with adequate market share and provider mix. . Strong reputation. · Coordinated local and regional services with minimum duplication. · Locally focused, responsive to community in order to improve health and enhance provider capacity. · High quality services, as measured by specific criteria and perceived by patients, families and providers. · Personalized service through recognizing then exceed individual patient/family needs POTENTIAL.ACTIONS. TO IMPROVE ACCE5.S In East Jefferson County ACTION 1. Assure essential health services are locally available. Essential means the services that are required to provide access to the most vulnerable and fragile residents of East Jefferson County. The report suggests local primary care and specialty physician capacity may not be adequate. Ultimately, this is a judgement call that can only be made by community leaders after considering the complex local professional relationships and impacts of additional physicians. A crucial underlying policy question is "what is the Board of Commissioner's vision for the balance of locally available versus regional services?" For example, a new facility which will include obstetrics and maternal care is being built in Silverdale by Harrison Hospital. Should a local OB/GYN be recruited to keep more deliveries in Jefferson County or should some OB services be regionalized at the new Silverdale facility? Recommendation: Hospital Commissioners could determine what constitutes essential services and decide if there is a lack of physician capacity. If yes, identify a process for determining specific additional capacity needed, pros/cons of adding that capacity locally and barriers that would need to be overcome (e.g. call coverage, income guarantees, office space). Develop actions to overcome recruitment and retention barriers. ACTION 2. Assure that all East Jefferson residents who are eligible for Medicaid and subsidized Basic Health Plan (BHP) are enrolled. In the broadest terms access to health care is usually equated with having some type of health insurance. From the perspective of enrollees, Medicaid is "free" and BHP can cost as little as $10 per month plus copays. Every resident enrolled in Medicaid or BHP represents additional state revenue coming into the East Jefferson health system. We estimate that each child enrolled in Medicaid brings approximately $1,200 per year to the health system (medical and dental) and a.BHP enrollee about twice that amount. Virtually all residents with incomes below 200% of the federal poverty level (FPL) are eligible for Medicaid or BHP with about 4,100 residents enrolled in 1998. In 2000,· a new Medicaid.:.like program called CHIP will extend coverage to all children with family incomes up to 250% FPL. Extrapolating from a 1999 OFM report on health insurance coverage, an estimated 1,450 people have incomes below 200% FPL but are uninsured. Covering these individuals through BHP, Medicaid and CHIP could attract an additional $2 million to the East Jefferson health system. Recommendation: Consider establishing an East Jefferson BHP S~on.sorship program. Program would include establishing local eligibility' criteria for sponsorship, outreach to eligible community residents, enrollment assistance, premium payments (partial or full). Funds would' need to be located to pay subsidized BHP premiums for eligible individuals and program can be limited based on available funds. A side benefit is that all individuals (mostly children and pregnant women) eligible for Medicaid or CHIP are automatically enrolled at no cost. The Health Department has a funding mechanism to off-set costs related to Medicaid! outreach, enrollment and administrative tasks. The Mount Adams Foundation in Yakima sponsers 10,000 farmworkers enrolled in BHP. ACTION 3. Explore revenue re-distribution systems to assure that local physicians who accept Medicaid and BHP patients are not unfairly financially penalized. While public insurance coverage provides access to enrollees, relatively low provider reimbursements may create income problems for physicians with large Medicaid/BHP patient caseloads. Equalizing reimbursements to providers requires a mechanism to redistribute funding. This is not a new issue for East Jefferson health care providers and it's overall benefit to improve community access to health care is promising. Recommendation: Research the political, legal and financial feasibility of promising options including: the De Leo Plan; community single payer project; hospital district employing physicians; a community-based entity accepting risk contracts for specific benefits (some hospital/physician); establishing a new physician employer entity (e.g. Compass in Whatcom County - half owned by physicians and half owned by management corporation). More ideas? ACTION 3A. Establish subsidized, cost-based reimbursement clinic in Port Townsend for Medicaid enrollees and uninsured residents. It would probably be possible to establish a special clinic that would be able to receive a higher level of reimbursement than private physicians for Medicaid and Medicare patients. Rather than redistributing resources to the current physicians, efforts could focus on creating a new clinic that would serve residents who were not able to access local private physicians. Recommendation: Decide if this option should be pursued concurrently with Action 3, or as a fall-back position to provide local Medicaid access. Research potential "clinic without walls" options to extend cost-based reimbursement to community physicians (unlikely). ACTION 4. Actively encourage small group/self employed insurance coverage. Small employers and self-employed people may need assistance finding affordable health insurance. It's a confusing maze, compounded by trying to understand which local providers contract for which products of which plans. The State of Washington has a consumer insurance information model for seniors called SHIBA. Many businesses may not know about options like the Chamber of Commerce or subsidized BHP for low-income employees. It may also be possible to organize a local small business buying consortia that could pool groups and potentially have more insurance plan choice and buying power. The collapse of the individual health insurance market makes encouraging small businesses to offer health insurance even more important. Recommendation: Develop a community strategy to market the importance of employer coverage and find ways to provide public information about options. Research the potential for a local small business buying consortia or purchasing coalition for health insurance. ACTION 5. Develop programs to help Medicare enrollees access affordable prescription drugs. This is an enormous and growing problem (which will likely effect non-Medicare enrollees in the near future as well). Many prescription drugs are expensive, Medicare does not cover drugs and many Medicare enrollees don't have enough money to buy the drugs they need. Recommendation: Work with 03A to research national programs to deal with the problem. Assess alternative purchasing strategies (e.g. Pequot scheme, 340B Prime Vendor contracts). Quantify the extent of the problem in East Jefferson County. Develop report on possible actions. AC.TION 6. Work toward finding options for individuals (with incomes too high to qualify for subsidized BHP) to purchase affordable health insurance for themselves and families. If all of the above actions are taken, the number of people without affordable health insurance would be limited to those who depend on purchasing individual policies. Currently, insurance companies are not offering these policies in most parts of the state and the only option is to enroll in the State's high-risk pool - which is largely unaffordable. Unless this problem is resolved during the next state legislative session, charity care and/or bad debt are probably the only short term options. Recommendation: Although the next legislative session may produce some options, the Hospital District could research the possibility of establishing a local "group" of individuals, associated by some factor other than health status. A coordinating organization would collect premiums from individuals, pay the plan,maintain enrollmentldisenrollment policies and enrollee lists. Action 7. Work toward assuring adequate availability of high quality health insurance plans in East Jefferson County. . The current situation is so unstable, this activity might need to be re-evaluated every year. What are the key characteristics of a high quality plan? What kinds of partnerships are expected? How many plans are enough? Too many? How can "good" plans be attracted to Jefferson County? "Bad" ones discouraged? .<' < t=¡ z ~ c.!:) < t5 ~ -æ ~ ,.J:¡ (;1 "E v .5 ...... t:: o U "'0 .- ¡.. ~ s ~ o o 00 ,.. := .... ëa a,¡ == .S:! ~ :g ~ ~ ~ .5 ,.J:¡ .... 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(;j v ::r:: v - ~ t:: v eI) "0 t:: ~ 00 v .~ - ~ "E v 00 ~ 0. v p::: '- o v 00 ;:3 o ::r:: ~ ::J o ~ -- 0. ;:J I 0. ~ 1-0 ~ ~ 0. o o N ~ 0. o ("1') N ~ ~ t:Q Ë 8 0. 0. o 0 ("1') 0 N ("1') :: ~ E: C) ~ .e. :.... ..... ~ \:3 "'J \:3 ~ ~ ~ U"J 1::: o 0. V p::: V {j :0 t:: ;:J o p::: U"J 0. ';:J "'ü) c: .9 ...... ~ 'ã) p::: U"J 00"0 .~ ~ 0.0 £CQ r,UJ ë; ;::...Ü ~ 0 "O......¡ v 1-0 .9] 00 ...... en 0 ;:J"C! ~ § :.a..r:: .8'~ ;::...v .-:: ::r:: c:....... ;:J 0 1::"0 o 1-0 o.~ 0.0 OCQ c: v ~ ...... I~ .... CI) U"J ;:j ~ 1-0 o en V .... .....0 - v 8 (;j~v 'ü ~ 8 g en..r:: ..... {);::: Ô .9 á3 ..r::..r::::r:: o .-:: ....... Z ~ 0 ..r:: ..... (;j v ::r: '- o en "0 ~ o p:) (;j u o ......¡ -- .9 -a v ::r:: '- o "0 ~ o CQ v ~ èI5 ~ o >-, Q -< ~ 0. o ("1') ("1') ~ Ë 0. 0. o 0 o 0 en 1.0 The Washington State Board of Health ·.·_;",'~;;~~:':';}'~W::M...~_-_-· New Commitments for the New Public Health Era Spring 2000 W"p. SIr.. BMN ;rH.... 1 (J1U!..~Sl OI)'IIIpt&. w......_ 91$0401990 ~236-4110 "',...- _.~.w"CO,,'''W History & Purpose , · Established by the Washington State Constitution in 1889 · Develops policies to promote, protect, and improve the health of Washingtonians Composition :t;:~tð'i'f:b~\_..;,S\'W · Ten members appointed by the Governor for staggered terms representing: · Consumers (2) · Elected City and County Officials (2) · Health and Sanitation Experts (4) · Local Health Officers (1) · State Department of Health (1) Board Authority ~~t-':'1";:;,"t~~,="~r-';":'~ -, · Sets Regulations for Many Local Public Health Programs · Makes Recommendations to the Governor, the Legislature, and other Agencies · Provides Public Forum for the Development of Health Policy · Provides Oversight · Conducts Research Major Areas of Regulatoay Authority · Communicable and Other Disease Reporting & Control · Immunizations · New Born Screening and Genetic Testing · Drinking Water · Sewage Disposal · Shellfish Management · Safe and Healthful Conditions In Food Establishments, Schools, Insütutlons, and Recreational Sites Recent Changes .", · New Chair and Many New Members , Fal/199B · New Staff . Fall- Winter 1999-2000 · New Commitments to Partners and Public Process New Commitments .."~:~~:.:.;:::;,,:~-:-~~~;c;.:.;..: · Direct Board Member Oversight and Direction of All Priority Setting, Rulemaklng, Research and Polley Development · Collaborative Work with Public and Private Partners Through Expanded Use of "Sub- Committees" · More Focused Efforts (Priority Issue Areas) · Greater Openness of Internal Operations · Streamlined Process Including Greater Use of Cyberspace ~'-.idt.wa.rWrbcW 2000 Priority Focus Areas .. · Children's Health and Well Being · Communicable Disease Reporting and Control · Environmental Justice · Health Disparities · Public Health Improvement Plan Contact Us Washington State Board of Health 1102 SE Quince St PO Box 47990 Olympia Washington 98504-7990 Phone (360) 236-4110 Fax (360) 236-4088 http://www.doh.wa.gov/sboh -EV_,...COM_OMCO '€'<DI.DCOCO-CO"l:tNO I-(J)MCO(J)(J)COI()NM WW~?""iß'iß-ofß"Ct"l""'"or.:t > ~~ ~~~ ::E + "'iij u o -' g .e I- W > ::E ] !;: o (!j -' « ü o CO(J)I() OV"" I() 'I" I() ~ - ~ ~ CO(J)I()O(J)I() N,...N<OCOCO O_'I"OCO(J) C').......,-~.....tß. ~~<h<h~ I() M N _fA....-C\l'V..-..-__C\.I ~<h<h~~<h<h~ ,...<O_COI()OO) _(OC")CO__C'),... . . cnl'C\J-.....C')V ~~;;;~¡;;~I~ __cnCO......_......C\I'Vv C)l.()"CtC")I.t)I.t)IJ)"I""'""'" COCO(J)'I",...NNNr-: ~ ~C\lC')NMa............o~Ov <O~C)N ro~roC')O~C\I~o~C')mNOO~ cnM......Ø......N......cnC)MroOC\l~......"Ct.....C)c:o~m......NON~<O~"I""'"mC\lC:O......o~ æg~~~~~~~~~~~~~~~~~~~~~~~g~~g~d~~~I: <O(J) co- ,...0 ~- <h ~ vl()(J) (J)OMCO (J)""""CO ~~tA-iØ M I() COO <.ON"""""" V(J)cÒM MæMiß. <h <h ,...V,... 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I I I 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 It) 0 It) 0 It) N N ~ ~ 0') 0') - >- LL en co 0') - >- LL en ...... 0') - >- LL en (Ø 0') - >- LL en It) 0') - >- LL en ~ 0') - >- LL en M 0') - >- LL en N 0') - >- LL en DECISION-MAKING FLOW FOR ADDITION OF NEW VAC(~/NES N A T I .0 , j,~ N A L The program determines the expense and resources necessary to follow the f recommendations including entitlement funds. / 2-4~S ¿ 1 month DOH Preliminary Policy Discussion 1-3 months The Immunization Program prepares a decision package for consideration by DOH. Approved decision packages are submitted to OFM in a Budget Request. ~ The Vaccine Advisory Committee considers the information, and makes recommendations to the I DOH regarding inclusion in schedule and school law. 'V 1-2 months If appropriate initiate WAC revision with the State Board of Health 1-2 months \~ \ 1-2 months The State Board of Health determines whether to initiate the WAC revision process II to make the immunization a school requirement. OFM reviews the recommends to the additional funding in Supplemental Budget. decision package and Governor for or against the Budget Request or If the Governor decides to include additional funding in the Budget Request, it becomes part of the Budget submitted to the Legislature. 4-6 months 8 months If the Legislature concurs, DOH has spending authority for additional vaccine. WAC revision process is completed. Vaccine is purchased through the CDC contract and distributed by the Immunization Program to public and "ivate providers through the local health departments. II FILE NAME. DMTVFC --- ! ¡ j I I I I 9 months 12 months S T A T E 15 months 18 months 21 months 24 months 03/2212000 Jefferson County Health and Human Services APRIL ~ MAY 2000 NEWS These issues and more are brought to you every month as a collection of news stories regarding Jefferson County Health and Human Services and its program for the public: 1. "Jefferson gets grant to aid transportation" - Peninsula Daily News, 4-9-00 2. "An invitation to a Community Forum" (ACCT grant) - P.T. LEADER, 4-19-00 3. "Transit for needy emphasized at Jefferson forum" - Peninsula Daily News, 4-23-00 4. "Jefferson faces septic plan lawsuit" - Peninsula Daily News, 4-17-00 5. "Safe food service earns recognition" - P.T. LEADER, 4-19-00 6. "Port Townsend: Public meeting set to discuss needle exchange" - Peninsula Daily News, 4-19-00 7. "Needle exchanges approved" - Peninsula Daily News, 4-21-00 8. "Needle exchange program approved by health board" - P.T. LEADER, 4-26-00 9. "Child art carries anti-smoking effort" - P.T. LEADER, 4-26-00 10. "State Bare Hand Policy Adopted" - WA Restaurant Assoc. News, Vol. 8 #10, April 2000 11. Washington State Responds: "HIV/AIDS Trainings to meet State Licensing Requirements" (2 pages) May/June 2000 12. "Mammograms suggested for Mother's Day" - P.T. LEADER, 5-10-00 SUNDAY, APRll.. 9,2000 AS Jefferson gets grant to aid transportation BY ADRIANA JANOVICH PENINSULA DAILY NEWS PORT TOWNSEND - A Dial- A-Ride vehicle pulls up at a resi- dence to take a woman living with a disability to a meal for low- income citizens. Moments later, a private trans- portation service arrives at the same residence to transport the woman's elderly mother to the same location. Under current laws, the mother and daughter - who reside together and often share the same destinations - do not qualify for the same transporta- tion services. The Agency Council on Coordi- nated Transportation has awarded Jefferson County a grant to help eliminate such a scenario. 18 months to change Intended to integrate special- needs transportation, the grant gives Jefferson Comity $20,000 for an 18-month period to improve coordination of trans- portation services. The program helps children, the elderly, and people with disabilities and/or low income, and satisfy the unmet transportation needs of special populations. "It's a beginning," Jefferson County Coordinator for Develop- mental Disabilities Anna McEnery said. She is acting as an agency council grant coordinator for Jefferson County. "With this grant, we'll be able to identify needs and take them back to the Legislature, who might say maybe these laws need to be changed," she said. Public comments Jefferson County Health and HUman Services Department hosts a public forum from 10 a.m. to noon on April 21 at the Pope Marine Building to discuss the grant and identify stakeholders and needs. Applications will be solicited to form an agency council coalition that will develop a coordinated transportation plan. Jefferson éounty Health and Human Services Financial Man- ager Mary Ann Preece-Rushton hopes the public turns out to par- ticipate in the process. "I really hope that we have a tremendous amount of participa- tion," she said. Jefferson County is one of 13 counties in the state awarded a total of $230,000 to develop coor- dinated transportation plans. Asotin/ Whitman, Grant/ Adams, Grays Harbor, Mason, Pacific, Pend Oreille, Snohomish, Spokane, Thurston and Walla Walla counties also received grants. Eliminate duplication The agency council on trans- portation was created by the Leg- islature in 1998 to help eliminate duplication and fragmentation of services, which can cause several vehicles to arrive at the same location to pick up only a few peo- ple with special needs. Jefferson Transit is one of the agencies involved with the plan- ning grant. "There are a lot of access needs that are not being met," Interim General Manager Melanie Bozak said. "(This grant) enables us to get to the point of knowing who needs what where. Once we know where the needs are - where the gaps are - we'll know what direc- tion to go." ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. .. .. .. .. 11 11 .. .. .. .. .. .. .. .. .. .. .. .. ~ ~ ~ ~ ~ ~ ~ ) I An !JhtJlta.tloh to a Community Forum that will be an exciting opportunity to have an impact on the future of transportation in Jefferson County. The people of Jefferson County invest significant resources in programs aimed at assisting children, the elderly, the poor and persons with disabilities. Many of those people cannot take full advantage of such programs, however, because of lack of coordinated transportation efforts. In an effort to help local communities improve specialized transportation services, the Washington State Legislature in cooperation with the Department of Transportation has created the Washington State Agency Council on Coordinated Transportation (ACCT). This new agency has awarded grants to Washington State Communities in order to identify local barriers affecting specialized transportation coordination efforts and in effect to design new methods of coordinated efforts. The local ACCT grant has been awarded to Jefferson County Health and ? Human Services. As the lead agency for this >./ grant they will begin to use the seed money ~ 1 -1 ~ to begin planning, designing and ~~~~- f.\\. implementing a coordinated transportation - \... ./ ,"-"/Jli.!.n- system for all of Jefferson County. To begin that process the Jefferson County Commissioners would like to invite organizations that transport people or which need public transportation in order for their clients to access goods, services, jobs and education to attend a community forum. This Coordinated Transportation Forum will bring together City government and representatives from human services, transit, paratransit, schools, community vans, ferry, taxis, carpool volunteer drivers and other concerned organizations, and the community. Date: April 21, 2000, 10:00 am - 12:00 noon Place: Pope Marine Building, Port Townsend, WA . ! hope you'll be able to attend this important meeting. We would welcome your input on the future of coordinated transportation in Jefferson County. 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Q P- Safe food service earns recognition The public is welcome to attend the presentation· of the 1999 Outstanding Achievement Awards for safe food ser- vice. These awards will be presented at the board of health meeting at 2:30 p.m. Thursday, April 20 in the Jeffer- son County Health and Human Ser- vices Department conference room, 615 Sheridan St., Port Townsend. This year 42 establishments and . their propJjetors will be honored for their high standards in safe food handling. Receiving the honor for its sixth year is Discovery View Retirement Center and Pat Carroll. Honored for five years are Port Townsend Senior Nutrition Program, Craig Yandell; Valley Tavern, Chuck and Karen Russell; Waterfront Pizza Upstairs, Katy Morse. Reœiving honors four years are Java Port, Linda Kennedy; Jefferson County Jail, Eleanor Such; Lonny's Restaurant, Lanny Ritter. Three-year honorees are Whistling Oyster, Sandra Van Wagenen and Wil- liam Bailey; Bread and Roses, Evelyn Dennison; Fat Smitty's, Carl Schnúdt; Nancy's Place, Nancy McConaghy; Peninsula Foods Deli, Hussein A. Saleh; Seabeck Pizza of Pleasant Har- bor, Jerry Anderson; SilverwaterCafe, Alison Hero and David Hero. Two-year recipients are Bloomer's Landing, Pamela Morgan; Brinnon Seniors, Lynne Fay; Cheeks, Sheila Piccini; Hard Rain Cafe, Michael Rasmussen; Jordini's, Amy Limber; Lanza's, Steve Kraght and Lori Lanza; Lighthous'e, Joe and Shirley Tso; Portside Deli, Lynda ánd Brian Dou- glas; Tri-Area Senior Nutrition, Linda HasIqns; QFC Port Hadlock Deli, Ron Reed; Stormin' Norman's, Norm Severson. First-year recipients include Ajax Cafe, Thomas Weiner; Cellar's Mar-· ket, Randy Unbedacht; El Sarape, James Gonzales and Mauricio Cisneros; El Sombrero Restaurant, Pedro Lopez; Heron Beach Inn, Joseph Merkling; Khu Larb Thai Restaurant, Paul Itti; Maxwell's, Chris Sudlow; McKenzie's Deli, Michael East; Niblicks, Pam Elkins; Pizza Factory, Francis and Valorie Danielek; QFC Port Townsend Deli, Jeannette Baker; Safeway Deli, Bob Giesler; Sentosa Sushi, Joann Saul; The Geoduck, ~urray and Sue Perley; The Upstage, Mark Cole; The Village Baker, Andre Le Rest; Uptown Pub and Grill, Laura Millett and Katy Snell. These awards are based on the fol- lowing criteria developed by the Jeffer- son County Food Service Advisory See FOOD, Page C 12 T,rr U;AD£'~ i{-fC¡-ðO Food· Continued from Page C 1 Committee: no more than 10 red points in anyone inspection; no more than 20 total points on any one inspection; no repeated red- point violations; two inspections, minimum, during the calendar year; selling potentially hazatd- ous foods; in business one year or more; open year-round; re- sponsiveness in correcting vioia" tions; no recurring food worker card violations. By meeting the preceding cirteria, these establishments· demonstrated tþeir effort to pre- . vent the spread of disease. by food and to 'protect the health, safety and well-being of the public. Thè health inspections show excellent compliance with the regulations set forth by the Washington State- Board of Health and the Jeffer~ son County Board of Health for the year 1999. QUICK READ Port Townsend: Public meeting set to discuss needle exchange Anyone who wishes to comment on a proposed needle exchange program can do so during a public hearing at 1:30 p.m. Thursday at the Jefferson County Health Department. The Syringe Needle Exchange Program would be part of the communicable disease prevention efforts of the health department. The program seeks to decrease public exposure to infectious diseases including HIV and hepatitis C from contaminated syringes. Other goals are to increase public safety through safe disposal of con. taminated syringes and increase contact by health professionals with injection drug users. For more information, call Jean Baldwin, direc- tor of Nursing Services for the county health. department, 360-385-4900. ~~~}~rf/;j'fi;: !~~5:rf4:.~~í5\~Ù~~,~,:·~~?f~: ~~'{t;;:~~~':\::' ~'"~I~~ ~t.fl\~~'~~ ~",~~;,~~: ': '~;: \~ ~,:', \ y " ~ç~ g ~,~ !', : 'fl) ~ L(- (7 - ð C) Needle exchanges approved BY ADRIANA JANOVICH PENINSULA DAILY NEWS Intravenous drug-users in Jef- ferson County will soon be able to exchange syringes through a pro- gram intended to reduce the spread of blood-borne diseases A resolution approving the nee- dle-exchange program passed the county Board of Health by a 6-1 vote on Thursday. About 25 "high risk" county residents are expected to partici- pate in the program, which would start in the near future. "The cost of inaction is high," said Thomas Locke, health officer for Jefferson and C1allam counties. "Syringe exchange programs reduce disease transmission, increase pub- lic safety and lead to increased treat- ment program referrals. TURN TO HEALTH/A2 '-I-;}) - Od Health: Differing views CONTINUED FROM A1 "Failure to take effective action does just the opposite." Earlier this year, Clallam County approved a needle syringe exchange program. Locke said he expects to have that program set up by July after a series of public meeting¡¡. "This is not a moral issue for us," board chairperson Roberta Frissell said. "It's strictly a disease preven- tion issue." Board member Sheila Wester- man agreed: "If we look at this from a strictly public. health standpoint, this is a no-brainer," she said. Huntlngford voted no Other board members include County Commissioners ,Glen Huntingford, Dan Harpole and 'Richard Wojt; Port Townsend Mayor Geoff Masci and Jefferson General Hospital commissioner Jill Buhler. Huntingford· cast the sole dis- senting vote. He said he regretted "that we didn't get a little better informa- tion regarding both sides of the issue," "I feel'kind of divided because it's the right thing to do, but we don't know the repercussions. Therefore, I'm going to be against adopting this. " State money from the county HIV Prevention Program fund will cover the cost for needles, an estimated $200 the flrBt year. Staff costs and time will be minimal, an estimated four hours a week. Board vice-chairperson Buhler stressed the county will not be giv- ing out free syringes. "A key word is exchange," she said. "We're not giving needles to people who don't already have them. We are exchanging dirty ones for clean ones." Controversl~1 program The resolution states that improper disposal of used sJI"inges threatens public health 1:íy'creat- ing a risk of unintended needle- stick injury and transmission of diseases such as HIV/AIDS and hepatitis. . ' . Locke called needle exchange progratnS "one effective strategy" for reducing disease transmission. Needle exchange programs remain a controversial issue. Con- gress has banned the use of fed- eral funds for such programs since 1988. During public testimony Thursday, county resident Milt Morris argued needle exchange programs do not reduce disease transmission but promote illegal drug use. "These programs have a his· tory of failure across the country and.throughout Europe," he said. "They become a taxpayer's nightmare. We are all going to regret it. I believe w~ will have created a network of drug users. I think you're, making a mistake." $yringe exchange programs lower the rate of new HIV infec- tions among injection drug users. Such programs do not increase drug use or crime rates, but reduce high-risk behaviors in addition to needle-sharing, he said. Encourages drug ÚS~? , Such programs· can also encourage drug userS to get help for their habits through referrals and adopt behavior changes that reduce the risk of disease trans- mission, he Baid. jefferson County Substance AbUse Program Advisory Board Chairperson Suzanne. Schniidt supported the resolution. . "W~ feel it would give us better access, better accountability," she said. The program also r,eceived sup- port from Executive Director of Jefferson Mental Health Services Laurie Strong, who ,offered her agency's participation as an exchange site. - Port Townsend &: Jefferson County Leader 1-z.¡,~où Needle exchange program :approved by health board By Miranda Bryant Leader Staff Writer Intravenous drug users will , be able to exchange dirty hy- podermic needles for clean . ones in Jefferson County soon, , following a majority vote of the 'Jefferson County Board of Health Thursday. A resolution to adopt a pro- gram was approved 6-1. Voting yes were Port Townsend City Mayor Geoff Masci, Jefferson County Commissioners Dan Harpole and Richard Wojt, Jefferson General Hospital Board member Jill Buhler, as well as citizen-at-Iarge members Sheila Westerman and Dr, Roberta Frissell, the latter of whom serves as the chairperson. Voting no was County Com- missioner Glen Huntingford, who said he didn't receive enough information from county health staff about the ef- fectiveness of needle exchange : programs in other com- : munities. . The health department could : 'implement the program this : summer. The exchange would , occur only once or twice a , month, The aim of the program is : to prevent the spread of disease : caused when intravenous drug : users share needles, such as : HIV and hepatitis Band t. At :-the same time, the programs , help drug users get into treat- , ment and health care programs as well as provide risk reduc- tion information. . The vote came after testi- mony and letters of support for the program from the Jefferson County Prosecuting Attorney's .office, the Jefferson County ',Substance Abuse Program Ad- visory Board, Jefferson Mental Health Services, and Dr. Tom ·Locke, health officer for the county. "We feel it will give a' little "The key word is exchange. We're not giving needles to people that don't already have them.", Jill Buhler of the problems in our area," said Suzanne Schmidt, chairwoman of the county Substance Abuse Program Advisory Board. Testifying against the pro- gram was Port Hadlock resident Milt Morris, who did extensive research on similar programs in other counties as well talking to local police officers and judges. Morris said the programs have failed throughout the country. He further contended that the system will only create a network for users searching for drugs. "The drug problem has grown because of these pro- grams," he said. His concerns about law enforcement's role in the pro- gram were later echoed in a separate interview with Port Townsend Police Chief Kristen Anderson. She speculated that arrests for drug paraphernalia could be tossed out of court if a person claims he was on the way to a government-sponsored needle exchange program. "It really is' going to come down to court issues," she said. However, the police chief noted that her opinion isn't the issue in what is a public health matter. "It does complicate our role in some of this, but we will deal with what decision is made," she said. Jefferson County reported being passed through shared needles, causing Morris to ask further questions. "I don't know what we'd ex- pect to solve by giving them clean needles," he said. However, about 300 used needles were found in Febru- ary 1999 at Cappy's Trail an:a in Port Townsend. The needles appeared to be used for insulin injections by a diabetic, ac- cording to police. However, a couple of burned spoons in- dicative of drug use were also found. Board member Buhler said there has been a misconception that the program would give free needles to drug users, "The key word is exchange," she said. "We're not giving needles to people that don't al- ready have them." Added Dr. Frissell, "It is not a moral issue for us, It is strictly a disease prevention program." Board member Westerman echoed Frissell's comments. When the Legislature acted to allow county board member- ships to expand, she was ex- cited at the possibilities of depoliticizing public health is- . sues. "If we look at this from a strictly public health stand- point, this is a no-brainer:' said Westerman. "If you let politics get into it, it gets mushy," For his part, County Com- missioner Glen Huntingford said he needed more rounded data to vote for the program. The only informatio,n supplied to the board telling of the nega- tive aspects of such programs was provided by Morris. Eleven Washington counties have needle exchange pro- grams. The Clallam County health board approved an ex- change program in January. Jean Baldwin, community health director for the Jefferson Students display designs 'r ~ .. · · Department, said she expects only 20 to 50 clients initially, The cost of new needles is es- timated at $200 a year, she said, making the program of mini- mal tìnancial impact. Baldwin said needle ex- change programs are impor- tant, considering the statistics. An estimated 36 percent of HIV infections nationwide are caused by sharing dirty needles. Sixty percent of hepa- titis C virus cases, which can lead to liver cancer, are associ- ated with needle use, accord- ing to the Center for Disease Control. Locally, the Clallam County Jail reported IS people going through detoxification from heroin this year, said Baldwin, and two people went in off the street to treatment centers in Jefferson County for detoxifica- tion. Users often don't meet the common stereotype, she added, They have families, jobs and homes. "They are everybody," she said. "It is very, very hard to know who they are." While the county health board's action April 20 estab- lishes a needle exchange pro- gram, the specifics of the pro-' gram are yet to be established. HAPPy 50th DAVE To a wonderful husband and Dad Love YOll, Nancy, Timothy, ¿Aaron; """,'" Mark & Vanessa Reasons to Leader Wednesday, April 26, 2000 . A 11 Child art carries anti-smokjngeffort By Janet Huck Leader Staff Writer Tobacco companies have spe- cifically marketed cigarettes to you£hs. "After all, cigarette mak- ers have to convert 3,000 new smokers a day to make up for the ones who quit or die," said Kelli Ragan, the Jefferson County Health and Human Resource. Department's substance abuse specialist. So Olympic Peninsula to- bacco prevention groups decided to target you£hs, too. With a grant from Washington Doc, a health care providers organization that focuses on tobacco-related health issues, Ragan and the Clallam Tobacco Coalition created an art contest for children from pre- school to high school. Six post- ers that feature an anti-smoking fact will be displayed in Jeffer- son County stores, businesses and schools. Every school in Jefferson County was given an opportunity to participate, and 42 entries were submitted. The youngest was from a 4-year-old. Most of the entries came from middle school students. No high school student submitted a poster. A panel of experts chose the six posters for the media cam- paign against tobacco. Each of the six artists will receive $25 worth of art supplies. "It was very hard to make the decision," said Ragan. "'They have a lot of wisdom, and they did a great job of putting their wisdom on paper." "I was surprised I won," said Katie Parent, a seventh-grader from Chirnacum Middle School. ''When my dad called me up with the news, I thought he was call- ing me to lift something for him, but he said I had Won." Posters created by the follow- ing six students were selected: Rose Burt, a first-grader in Katie Parant, a seventh-grader at Chlmacum Middle School,ls one of six selected artists whose posten! will be used In an antJ.cmoidng media campaign. '"'!~ , "/ . Courtøsy of Katie Parsnt .' OPEPO alternative school at Mountain View Elementary School in Port Townsend, drew a pregnant mom and dad smoking. ''When women smoke, they hurt their babies," Burt wrote. Ragan plans to make Rose's drawiD.g into a refrigerator magnet. Chelsey Hoglund, a first- grader at Grant Street Elemen- tary School in Port Townsend, wrote a blunt statement: "Don't smoke because it kills you." She illustrated it with the image of a dead person lying next to a tomb- stone. The person looking at the grave is very sad. Arlo Evasick, a fifth-grader at Ch.imacum Elementary School, wrote: "If you want to keep your teeth stainless and in your mouth, don't smoke. It's sticky brown stuff that stains your teeth and clogs your lungs." , '~ ,..j': She ehded the list ~ili thé best teenage reason: "It DlÙc$ you look totally stupid.;' : . , Simon Rowe, á flfth-graderat Chimacum Elementary School, wrote: "Tick, tick, time.'s up. Every 13 seconds someone dies from a tobacco-related illness." He drew a horse smoking. Thir- teen seconds later, the horse keeled over dead. Michael Loring, an eighth- grader at Brinnon School, provided a direct ·message. He drew a picture of a Kodiak can of chewing tobacco and wrote: "This product causes gum cancer." Seventh-grader Katie Parent gave clear and direct refusal ta the offer of a cigarette: "No Thanks!" But she also crammed in nearly every reason not to smoke, including: It empties your wallet, clogs your lungs, gives you emphysema, heart disease and cancer. "I didn't want to explain ev- ery kind of cancer you get," she laughed. State Bare Hand policy Adopted Last Summer, WRA, Washington State Department of Health, Washington State Food Dealers Association (Grocers) and several local health departments agreed to and adopted a model policy for bare hand contact on ready-to-eat foods. Although local health departments still have separate rule-making authority, this was an important first step toward a statewide unified policy that is based on reason, science and good public health. AS~P~u'7~ In the United States, infected food workers are the source of contamination in approximately one out of every five foodborne disease outbreaks reported. Many of these outbreaks could be prevented if food workers would take appropriate precautions before handling food. Beyond the dire health implica- tions, three things occur each time a foodborne disease outbreak in a restaurant becomes public: . The restaurant, unless a national chain, will almost always go out of business, · Public confidence in eating away from home decreases, and . Industry sales take a dip. Local and similar menu concept restaurants are especially hard hit. 7Æe 1teev- State 'P~ While the guideline does not prohibit bare hand contact with food, it does state food workers should, whenever practical, use barriers such as tongs, spatulas, deli tissues, dispensing equipment, and scoops to prevent ~.(" ù""Y"-v Lv ~5 ~ ;ASlo,^ b<PS-t&.......". '"'~ i contact between bare hands and ready- to-eat foods. In instances where it is not practical to eliminate hand contact with ready-to-eat food using these barrier methods, businesses should ensure methods exist to further reduce the risk of contam- inating food with human pathogens by: I) Ensuring employees wash their hands prior to handling ready-to- eat foods; and 2) either Establishing methods to document, monitor and verify handwashing, or Ensuring employees use an alternate barrier, such as single use gloves. Implementing these methods will reduce the risk of foodborne illnesses that is spread by bare hand contact with ready-to-eat foods. '!)~, ~ ~ 1Ie'#f What the new guideline means is that touching ready-to-eat foods with your bare hands is a privilege, not a right. In order to have this privilege you must have a handwashing program in place that documents, monitors and verifies that your employees are in fact washing their hands. Too difficult? Then simply use barriers instead of your hands when preparing ready-to-eat foods. But if barriers are impractical in your business, you must develop a system which includes all of these three steps: Document: the existence of a policy that assures that proper hand washing occurs. Documentation can include handwash logs, automated handwash ·:':--ní<""'2ÕÍJÕ-~~._·>' . ..~ ~__~AP._.J_.__.......__i;;~}fQVjOO ." i1ëC:,-'c..)' /~\ ?'.;.>.J U l l c;{, ù '"",, I\,)0'- Lv 'S . systems, soap clickers, handwash timers or other verifiable tracking systems. Monitor: to assign/designate the responsibility of assuring the handwashing policy is carried out. Techniques will vary considerably. In most cases, the monitor will be a manager who is designated responsible for ensuring handwashing happens at appropriate times. Verify: the ability to con~rm that the handwashing policy is in place, being used and monitored. No additional documentation is necessary for verification, but regulators should be able to see that the program is effective. Aa~ With the outbreaks that have occurred statewide and the spread of the new foodborne diseases, don't wait for a disaster to ruin your reputation and business. The Department of Health and the WRA encourages all restaurants and local health jurisdictions to: · Take strong, reasonable approaches to reduce the level of bare hand contact with ready-to- eat foods, · Continue to make education about and enforcement of handwashing a top priority, and · Adopt the state policy to signifi- cantly reduce the amount of bare hand contact to ready-to-eat food. For the state model guideline, Q&A. and a printable handwashing log form, visit our website at www.WRAhome.com. and click on April newsle!ter supplement. Check with your local health ~. ""i;" department for the rules regarding bare han~ contact with ready-to-eat foods in your area. Vùi6 Ji~,-;' I ~CnCì #- I ù WASHINGTON STATE RESPONDS PROVIDING EDUCATIONAL INFORMATION ON HIV/AIDS & OTHER INFECTIOUS DISEASES AND REPRODUCTIVE HEALTH May/June 1000 TABLE OF CONTENTS State Licensing Training Calendar........................ 1-3 Calendar Section ....... ............................................4-6 Region 1 & Region 2 ............................................7-8 Region 3 & Region 4 .......................................... 9-1 0 Region 5 & Region 6 ........................................11-13 Statewide News...............................·..·........· .......... 14 my Prevention Community Planning.............. 15-16 Noteworthy Websites ................................... .......... 16 my Focus ....... ....................... .......................... 18-21 STD Focus.....................................····..·······..··..· 22- 23 Case Manager Update .......................................2~-25 Family Planning Focus...........................·..·............ 26 TB Focus .......... ................................................. 27 - 29 Suggested Reading ....................... ..................... 30-33 Washington SID Statistics ...............................34-35 Washington AIDS Statistics............ .................. 36-3 8 Washington Tuberculosis Statistics ....................... 39 HIV/AIDS Trainings to meet State Licensing Requirements Location Phone Number 2-,4-, or 7-hour Cost Other Details Course Anacortes (360) 299-1342 4 hr; 7 hour video No charge. Offered by Island Hospital. courses For residents of Island, Skagit and San Juan Counties only. Bremerton (360) 475-7359 2 hour $10 Offered by Olympic College in (Kitsap County) Bremerton Coupeville (360) 678-5151 4 hour; 7 hour $20 Offered by Island County Health (Island County) Dept. and Whidbey General Hospital. Everett 1-(888)-715-5815 2 hour $20 Offered by Education Express. (Snohomish County) They will travel. and throughout W A. Everett (425) 252-4103x12 2 hr; 4 hr; 7 hour $15 for 2 hour Offered by the American Red (Snohomish County) Shirley $20 for 4 hour Cross. Scholarships are $50 for 7 hour available. F orks/Pt. Angeles (360) 374-7554 Additional classes on Cost varies. Offered by Olympic Community (Clallam County) 1-(888)-234-5185 care giving, grief, and Health Associates. Continuing other issues. ed. Credits may be available for these classes. F orks/Pt. Angeles (360) 374-7554 2 hr; 4 hr; 7 hour $25 for 2 hour Offered by Olympic Community (Clallam County) 1-(888)-234-5185 $35 for 4 hour Health Associates. Scholarships ocha@olypen.com $55 for 7 hour available. Ilwaco (360) 642-2869 4 hour, 7 hour Cost varies Offered by Ocean Beach (Pacific County) Lynn Roy Hospital Mt. Vernon (360) 428-2151 4-hr, 7-hour videos $25 handling Offered by Affiliated Health fee tapes Services. Mt. Vernon (360) 424-5291 2 hr; 4 hr; 7 hour $20 for 2 hour Offered by the American Red $30 for 4 hour Cross. $40 for 7 hour A Public Information Project of the Washington State Department of Health. Office of Infectious Disease and Reproductive Health http://www.doh.wa.gov/cfh/hiv_aids/prev_edu May/June 2000 Serenity House (a homeless shelter), and the Area Service Agencies in Clallam County on both lIIV prevention and the services that CLASP offers. In other news, CLASP looks forward to again being a part of the Clallam County Fair in August, where they will have a booth with lots ofHIV information! CLASP also is planning a book and gift sale in September. For more information, call Evelyn Linton at (360) 452-1932. Sandi Kendrick, a Health Educator from the SW Washington Health District, has been working with the blind and the developmentally disabled communities to initiate sexuality education, including HIV education, classes. Sandi is also interested in talking with anyone who has experience working with these "different!y- abled" populations. To reach Sandi, call (360) 397-8254. Lana Rosten-Mahoney and also an HIV-positive man and his caregiver recently spoke with a 7th grade class at Forks. Juanita Wissenfels, a math teacher, does three health classes a year and always asks for an IDV-positive speaker to address each class. Lana has also taught a lO-hour DASA IllV/AIDS class through Peninsula Community College in Port Angeles. She will be teaching lIIV prevention to three groups of alcohol and drug treatment classes through West End Outreach in Forks in May. Other classes that Lana has scheduled are a review for the National Park Service staff at Kalaloch, and an annual review for La Push Headstart staff and parents. For more information, call Lana at (360) 417-6255. The Board of Health in Jefferson County has approved a needle exchange program for injection drug users. The board voted 6 to 1 to start the program quickly, and about 25 area residents are expected to participatê. The program aims to reduce lIIV transmission and lead to more drug treatment program referrals. Jean Baldwin, the Community Health Director, and Kellie Ragan, Intervention Specialist, did an enormous amount of research and education in the community; their hard \york paid off in the approval of the syringe exchange. A big thank you to Jean and Kellie! For more information, contact the staff of the lIIV/AIDS Program at the Jefferson County Health Department at (360) 385-9421. A Public Information Project of the Washington State Department of Health, Office of Infectious Disease and Reproductive Health http://www.doh.wa.goy/cfh/hiy_aids/prey_edu May/June 2000 13 Mammograms suggested for Mother's Day Along with flowers and chocolate on Mother's Day, those looking for special gifts may want to remind the women they care about to get a mam- mogram. The Jefferson County Health and Human Services Department recommends that women regu- larly r~ceive a mammog"ram - a low-dose X-ray of the breast and the most effective method of detecting breast cancer in its ear- liest, most treatable stage. This year an estimated 184,000 women will learn they have breast cancer, the most common fonn of cancer among American women. The encouraging news is that with early detection and prompt, appropriate treatment, the outlook for women with breast cancer is good. Mammograms are recom- mended everyone to two years, starting at age 40. Yearly screening mammography is es- pecially important for women ages 50 and older because the risk of breast cancer increases with age. In addition, most cer- vical cancer deaths could be prevented if women got a pap test everyone to three years. Women throughout Wash- ington state may qualify for a 1>~ L . ~ V? I' ì. éAD t:;,,-- [;-(0 -- CJO free women's health exam through the Breast and Cervi- cal Health Program (BCHP). BCHP is a limited health- screening program federally funded through the Washíngtei'n State Depart?1en t of Health and is in turn available locally through the health department. The program screens women for cervical and breast cancer and provides referrals for fur- ther services if needed. This program is in its fifth year in Jefferson County. More than 300 women have partici- pated, according to public health nurse Marty Joh~son. For eligible women, BCHP services include a clinical breast exam, education on how to do self-breast exams, a mammogram, and a pelvic exam with pap test. To qualify, women need to be age 40 to 64, have low income and limited or no health insurance. For more information and to learn how to qualify, call Jefferson County Health and Human Services, 385-9400 or 1-800-756-5437. Ask for the Breast and Cervical Health Program. "Don't delay," Johnson said. "Early detection is the best pro- tection."