Health bureaucracy gets a double take

At first blush, it looks like just another bureaucratic shuffle. It isn’t.

In fact, the move to carve out a new state Department of Public Health reflects a shift in California’s attitude toward fighting disease and confronting health emergencies–including those prompted by terrorism and fears of epidemics, such as avian flu. The department is patterned in part after the kind of agency that all 58 counties and three cities–Berkeley, Pasadena, Long Beach–already have, by law. It will be run by a medical doctor known as the state’s public health officer–the state’s “Top Doc” or “Papa Doc,” as the position already is being dubbed–and it will have more than 3,000 employees. Above all, it represents a dramatic cleavage in the state’s bureaucracy.

Some believe it also represents–not unlike other programs envisioned by Gov. Arnold Schwarzenegger’s administration–a return to the arguably halcyon days of former Democratic Gov. Pat Brown, who seems increasingly to be a role model for the current governor.

Schwarzenegger’s move to rebuild the state’s massive infrastructure system is also popularly viewed as a hearkening back to Brown.

“We are going back to the future–when we were best,” said Bruce Pomer, executive director of the Health Officers Association of California, the sponsor of the new law and a 34 year health-policy veteran. “We had a state Department of Public Health, and it was recognized as the finest public-health organization in the world. If you were even a section chief, you were a world renown scientist, and you were consulted around the world.” That system was changed as lawmakers decided to consolidate services.

Making sweeping changes in the bureaucracy isn’t easy, Pomer added. “If you want to start World War III, just screw around with a bureaucrat’s turf. There’ll be a mushroom cloud over your head and you’ll be gone.”
But thus far, despite the dire predictions of Capitol insiders, the division is going smoothly.

That’s at least partly because the legislation authorizing the split, SB 162 by Sen. Deborah Ortiz, D-Sacramento, also sets up a body to manage the intricate dance of dividing the two huge bureaucracies. It’s also because Schwarzenegger supports the idea, as do his top health officials and numerous interest groups, including the California Medical Association, assorted local public-health and environmental interests, and the Little Hoover Commission, among others. There was no formal opposition to Ortiz’s bill as it moved through the Legislature, unlike her original proposal in 2003, which died in Assembly Appropriations during the Davis administration.

“It’s very consistent with the governor’s commitment to embrace public-health goals,” said Health Services director Sandra Shewry, who aggressively backed the reorganization. “We could do a better job in improving the health status of the public if we had two departments, each of which could focus on a more narrow portfolio.” Shewry’s office posts regular updates on the transition to two entities, provides detailed information on job changes and tells employees what to expect.

“There was also a push by public-health officers at the local level to have a central doctor at the state level,” said Ortiz spokeswoman Hallye Jordan. “Bioterrorism, the avian flu–those definitely did raise public awareness about the dangers of these types of infectious and contagious diseases, and put pressure on state policy makers to improve California’s awareness.”

By next July 1, the state’s 6,000-plus employee Department of Health Services will be divided into two pieces. The split is part of Schwarzenegger’s 2007 health-care plan, which he’ll unveil in January and that likely will dominate next year’s political wars.

The first piece, to be called the Department of Health Care Services, will handle the $35 billion Medi-Cal program, the nation’s largest state-health system, which provides health care to 7 million poor Californians through a mix of state and federal funds. The DHCS will administer other programs, such as the Genetically Handicapped Persons Program and the California Children’s Services effort, but its principal function will be to focus on the huge Medi-Cal program. The head of the new DHCS, an appointee of the governor, has not yet been chosen, but that person is all but certain to be Shewry, according to Capitol sources. The DHCS budget is likely to be in the neighborhood of $36 billion.

The second, the Department of Public Health, is envisioned as a hands-on, health-protection agency that will quarterback the response to health emergencies, such as the spread of infectious diseases, environmental catastrophes, bioterrorism attacks and the like. The DPH also will have jurisdiction over scores of health programs, such as West Nile virus, AIDS prevention, sexually transmitted diseases, tuberculosis, diabetes, oral health, asthma, epidemic investigations, drinking-water safety, nuclear emergencies and myriad of other issues. The head of the new office is likely to be Dr. Mark Horton, a physician who currently serves under Shewry, and his department budget is likely to be in the $2 billion range.

Under the new scheme, both Shewry and Horton will report to Kim Belshe, Schwarzenegger’s secretary for Health and Human Services and his ranking health official in California.

One thorny issue, apparently resolved, is nursing-home inspections, a critically important and politically sensitive function handled by DHS’ Division of Licensing and Certification. That office had been envisioned as part of Health Care Services, but has since been placed in the Department of Public Health.

The split is not supposed to entail either cuts or more spending, but some are wary.

“This proposal is supposed to be budget neutral, but people who are a lot more experienced than I am in reorganizations say that is not always the case,” said Diane Koehler, a health facilities evaluator nurse at the Licensing and Certification Division office in Daly City. “The problem is that public health departments are the first to feel any budget cuts at all, she said.”

Contact John Howard at

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