The state’s public health division has been whittled down significantly over the past several years and is facing more cuts this year.
The Alaska Department of Health and Social Services has been high on the chopping block for a Legislature looking for places to cut expenses in the fiscal year 2018 budget. The Senate passed a budget on April 18 cutting another $29.2 million out of the department’s budget, on top of a $1.5 million reduction in the final fiscal year 2017 budget passed last year.
The House of Representatives is still debating it, but if the cuts go through, one area that will feel them strongly is the Division of Public Health. Unlike other states, where the counties or boroughs run their own public health programs, the state runs one for the entire population of Alaska outside Anchorage, with a network of traveling nurses and public health centers to provide basic services such as well child exams and vaccinations. However, due to budget cuts, several centers have had to be scaled back or closed within the last few years.
The Senate’s proposed budget cuts Unrestricted General Fund dollars from the Public Health Nursing section by an additional 5 percent, “with the expectation that PH Nursing collaborate with other Health Centers,” according to the Conference Committee motion document.
Division of Public Health Director and Chief Medical Officer Jay Butler said nothing is decided for sure, but if the division does have to take the cut, they’ll have to make them thoughtfully. Cuts have already led to a series of service reductions across the state, he said.
“With those cuts of nearly 20 percent to DHSS over the last three years, we’ve had to reduce statewide services, with basically very little for people over age 29 now,” he said. “It sort of breaks my heart when people call me and say they’ve always gotten their first shot at the public health center and they can’t do that anymore.”
Cuts to the Medicaid program will also ripple through the Division of Public Health through matching, he said.
Public health nurses don’t just administer shots and provide tests for sexually transmitted infections — they also investigate epidemic outbreaks of diseases and provide a safety net for basic medical services. For example, when an outbreak of whooping cough occurred in Homer last year, it was the Section of Epidemiology that started gathering information on infections from private physicians and hosting a vaccine drive.
But as the budget for public health gets slimmer and slimmer, fewer nurses can travel to remote communities and fewer regular services are offered. There are no full-time nurses in Cordova, Haines, Wrangell and Seward, and as more positions are cut, there are only so many people who the department can send out, Butler said.
“At some point, you can’t have more work done by fewer people,” he said. “You do less with less because you phase things out. There’s no more efficiency to be gained.”
More of the burden has shifted to organizations like community health centers, which like public health centers offer sliding-scale payment systems. Seward Community Health Center had to step up when the Seward Public Health Center’s one full-time nurse retired, leaving the public health center there as an outpost to be visited by a traveling nurse from Kenai. But there are situations public health nurses are set up to handle that community health centers aren’t equipped for, such as a mass disaster or epidemic, said Seward Community Health Center Executive Director Pat Linton.
“You cannot make a simplistic conclusion that if you close the public health centers that the community health centers will pick up the work,” he said. “That’s not true. That’s impossible.”
Epidemiology is unique to the state’s public health nurses, Butler said.
“Community health centers are really focused on providing individual access to care, whereas public health centers are better at looking at (larger questions),” he said. “That is a somewhat different mission, and oftentimes what the public health centers do are much less likely to be billable services.”
Public health is a long-range game. Programs implemented tomorrow can take years to show measurable results. Amid the conversation of health care reform and reducing costs, a common question has been held forth by industry members, regulators and activists, known as the triple aim: How do we get better health for more people at a lower cost?
Linton, who retired at the end of April, testified to the Senate with Butler and Head Public Health Nurse Linda Worman about the effects of cutting too far into public health services. The state has already worked out some partnerships to cut costs, like in the case of the Healthy Alaskans 2020 public health effort — when federal support for that effort lapsed, the state worked out support in partnership with community and private organizations, he said.
“Health is one of those fundamental aspects of life that we oftentimes take for granted and when we lose it, we really begin losing everything — relationships, wealth, property,” he said. “The protection of health is one of a lot of things that Alaskans hold dear.”
Reach Elizabeth Earl at firstname.lastname@example.org.