In the St. Louis region, public health department services are primarily delivered through either the St. Louis City or the St. Louis County health department. According to the National Association of County and City Health Officials (NACCHO) , this model is consistent with the 68% of local health departments across the nation that serve at the county level and an additional 20% that serve at the city or town level – the remaining 12% either serve multiple counties or some other configuration of multiple cities or counties. ^[1] Given the status of St. Louis City as both a city and a county and the significant population of residents within unincorporated parts of St. Louis County, it is imperative that an examination of municipal-level services in the St. Louis region include a discussion of health services delivered by these governments. This report aims to identify any major benefits or challenges related to the delivery of governmental public health services in the St. Louis region and, where appropriate, offer potential paths forward based on current local practices and lessons from other regions that have undergone similar thought processes. To this end, this report will examine the similarities and differences in public health statutes for St. Louis City and County, identify current areas of cooperation, and offer feedback from public health professionals on the possible benefits of a more regional public health department.

In June 2005, the Regional Health Commission released a supplement to their Community Health Infrastructure Assessment called the “Governmental Public Health Services Study for St. Louis City and County." The stated purpose of this study was “to provide a fact-based ‘snapshot’ of governmental public health services currently provided in St. Louis City and St. Louis County.” ^[2] This review of the services provided by the City and County Departments of Health was performed to determine the feasibility of dissolving the two entities in favor of creating a new entity that would serve as the health department for the St. Louis City and County region. While this dissolution did not take place, there are many important lessons to be learned from the report produced by the Regional Health Commission. These lessons range from observations about funding sources and fee collections to differences in services provided by each entity and overall staffing differences. The following section will highlight the relevant observations that are found in the 2005 study.

Funding

Chief among the differences between the city and county departments of health is the way in which each is funded and the amounts they spend. Both the City DOH and County DOH receive their funding from a combination of sources including local taxes, grants and contracts, and licenses and fees. However, the breakdown of their budgets by revenue source reveals important differences. Specifically, 51.5% of the St. Louis City DOH budget is from grants and contracts with the remainder from a local use tax. ^[3] In contrast, only 3.5% of the County DOH revenues come from grants. ^[4] Meanwhile, St. Louis County has a dedicated property tax rate of 0.14 cents for every $100 of assessed valuation. ^[5] This tax accounts for 61.3% of the County DOH budget. The city currently has no such tax and thus must rely on other funding sources, such as the use tax fund, to carry out its mission.

The scope of this contrast becomes more apparent when examined in the context of the respective budgets for the City and County Health Departments. The City DOH operates on an annual budget of $25 million, while the County DOH has a budget of $57 million. ^{[6] [7]} This means that approximately $12.98 million of the City’s DOH budget is from grants and contract dollars, and only $1.85 million of the County DOH budget is from similar sources. This difference becomes more significant when considering how each department sets its operational priorities and will be revisited later in the report.

Another area of difference between the City DOH and County DOH is the fee collection for direct services. The “Governmental Public Health Services Study” notes that fees for services “such as patient visits, inspections, and vital record certificates, are managed differently in the City DOH and County DOH”. ^[8] The clearest two examples of this difference are in the patient visits and vital record certificates. As will be further explored in the next section, the City DOH does not provide primary clinical care to residents and thus does not collect or earn revenue on those services. The County DOH, on the other hand, does provide primary medical care through the three health centers it operates. The fees collected from these services go directly back to the County DOH and help support its overall mission. Likewise, the City DOH does not administer birth, death, or marriage certificates – these certificates are issued through the St. Louis City Recorder of Deeds office. ^[9] This is a deviation from the way both the County DOH and the majority of health departments across the nation function. The revenue from user fees for these and similar services – including restaurant inspections – totals over $10 million a year for the County DOH. ^[10] The City DOH fees for restaurant inspections and fines total about $1 million a year. ^[11] All money collected from any health-related fees and fines in the city go back into the general revenue fund. Finally, with regard to funding, the last major source of difference between the two departments of health is in their overall spending. As noted earlier, the City DOH has an annual budget of approximately $25 million while the County DOH budget is $57 million. This variance in budgets can primarily be attributed to differences in population, geography, and service function areas. St. Louis City has a population of 318,416 and St. Louis County has a population of 1,001,444. ^{[12] [13]} Additionally, St. Louis City is 61.91 square miles while St. Louis County is 507.80 square miles. These differences mean that delivering similar services in the City and County have disparate costs. For example, providing comparable vector control would necessarily cost more for St. Louis County given it is more than eight times the geographical size of the City of St. Louis. Similarly, the population difference between the two entities influences the amount of funds required to adequately deliver public health services to its citizens. Lastly, as the next section will discuss, primary care for those citizens without health insurance is handled differently between the City and County departments of health. This combination of factors helps explain the differences in overall budgets for the St. Louis City and St. Louis County DOH.

Health Centers & Direct Medical Care

One of the most significant ways in which the St. Louis City DOH differs from the St. Louis County DOH is in the delivery of primary care medical services for individuals without private health insurance. Currently, the City DOH does not operate its own health centers for primary health care. Instead, they contract with the Regional Health Commission to provide primary, specialty and urgent cares services through the Gateway to Better Health Medicaid Waiver program. $5 million of the City DOH budget is put toward these efforts and matched by $25 million in federal funds to provide services. These services are delivered through private agencies such as BJC Health, SLU, SSM, and four Federally Qualified Health Centers (FQHCs) – Betty Jean Kerr People’s Health Centers, Family Care Health Centers, Grace Hill Health Centers, Inc., and Myrtle Hillard Davis Health Centers, Inc. ^[14] While there are FQHCs in the St. Louis County, comparable services are primarily provided through the three community health centers that the County DOH directly operates. In addition to operating three health centers, the County DOH also delivers medical care services to inmates in the St. Louis County Corrections system. In contrast, the City of St. Louis Corrections department contracts with outside vendors to provide medical care for its inmate. ^[15]

Cultural Issues

The exploration of combining any two entities requires an acknowledgement of cultural similarities and differences that may need to be addressed. Some of these issues reveal themselves in how funds are spent for the City DOH and County DOH. For example, the “Governmental Public Health Services Study” notes that while both health departments rely on contracted vendors to carry out their missions, the City DOH spends 24.1% of its budget on contracted services while the County DOH spends 3.4%. ^{[16] [17]} These differences are further highlighted in the number of full-time employees in each department. The County DOH has 519 staff members, while the City DOH has 142. ^{[18] [19]}

Another key difference in the respective cultures is how each DOH defines its service areas. While similar terminology is used to describe their divisions, the definitions of those terms are not always congruent. For example, both departments have environmental health divisions , but what is included in those divisions is not the same. In the County DOH, the environmental health division includes a pollen and mold center, an air pollution control program, lead poisoning prevention efforts, and solid waste management . The City DOH environmental health division includes food and beverage control (restaurant inspections), air pollution control, vector control and animal care and control. The City DOH maternal, child and family services division has lead testing services , asthmas services, smoking cessation services, day care and school health nursing services. Some of the distinctions can be attributed to existing collaborations between the departments. One such example of this collaboration is with the aforementioned pollen and mold center, which does air quality assessment for the region. Other differences are related to overall organizational structure within the City and County governments. Specifically, solid waste management and recycling for the City of St. Louis are functions of the street department. Ultimately, the differences in alignment of services are largely tied to organizational structure and semantics rather than a large variance in service levels. These challenges are not insurmountable but it is critical to acknowledge them and ensure they are navigated appropriately.

Despite differences in culture, the two health departments partner in a number of areas. Below are examples of programs in which the City DOH and County DOH already collaborate in some capacity. ^[20]

A. 5 State Regional Health Equity Council

B. Operation Weather Survival

C. Public Health Information Distribution

D. State/National Accreditation

E. Health Access Coordination

F. BioWatch Air Sampling

G. Public Health Emergency Planning

a. Mass Sheltering

b. Federal Medical Shelters

c. Medical Support Teams for Shelters

d. Mass Casualty Response

e. Behavioral/Mental Health Response

H. Public Health Incident Command

I. Asian Restaurant Task Force

J. Food Safety Task Force

K. Missouri Milk Board

L. Food Program Standards

M. Ice Cream Machine/Milk Testing

N. HIV/AIDS Prevention and Ryan White Services

O. Immigrant Entry Health Assessment

P. Communicable Disease Investigation

Q. STI Investigation

R. TB Control

S. Epidemiology Data Sharing

T. SIDS Services

U. Asthma Home Assessments

V. Asthma Prevention

Other Health-Related Services

Although not housed within the City or County health departments, there are a few services in both St. Louis City and County that are relevant to the conversation. In St. Louis County there are the Children’s Service Fund (CSF) and the Productive Living Board , and in the City there is the St. Louis Office for Developmental Disability Resources (DDR) and the St. Louis Mental Health Board (MHB). The PLB is an independent agency established by the Missouri Legislature to provide services to residents of St. Louis County living with developmental disabilities. ^[21] Its board is appointed by the St. Louis County Executive and is funded primarily through a dedicated property tax rate of $0.089 per $100 of assessed real estate ($0.090 for agricultural, commercial, and personal property). ^[22] Similarly, the DDR provides services to residents in St. Louis City living with developmental disabilities. Like the PLB, the DDR operates as an independent government with a board appointed by the St. Louis City Mayor and has a dedicated tax rate of $0.15 per $100 of assessed value. ^[23]

The CSF is an agency of the St. Louis County government with a board appointed by the St. Louis County Executive. The CSF was created “to provide mental health and substance abuse services for children and youth ages nineteen and under in St. Louis County.” ^[24] Its funding comes from a dedicated ¼ cent county wide sales tax. ^[25] In the City of St. Louis, there is a comparable fund referred to as the Community Children’s Service Fund (CCSF) that is managed by the MHB. The MHB is a special tax district created via Missouri Statute whose board is appointed and approved by the St. Louis City Mayor and Board of Aldermen. The MHB “administers public funds for behavioral health and children’s services for the benefit of city residents.” ^[26] The CCSF receives its funding from a dedicated property tax of $0.19 per $100 of assessed property value. ^[27] Also administered by the MHB is the Community Mental Health Fund (CMHF). This fund “[invests] in services that target adults with serious behavioral health conditions.” ^[28] The CMHF receives its funding from a separate dedicated property tax of $0.089 per $100 of assessed value. ^[29] While the PLB exists in the County to provide services to individuals with developmental disabilities, there is currently no designated fund specifically designed to address mental health needs for adults, comparable to the CMHF.

Even though none of these entities are directly a part of the City or County departments of health, they play a critical role in the delivery of health services in the region. While not fully within the scope of this study, they certainly merit understanding and any proposals regarding a change in the delivery of governmental health services within the region should further explore the implications for these health agencies.

Community Outreach Data

One of the cornerstones of the Better Together process is input from members of the community about their experiences with the delivery of municipal-level services. For the public health study, Better Together staff convened a committee of public health and health care professionals to advise the research process and better understand the views of those who work most closely with the health departments. A full list of committee members can be found in the appendix. Over the course of the study on public health Better Together staff met with dozens of community members and leaders, including local doctors and nurses, health nonprofit executives and staff, former state health department officials, elected officials, Saint Louis University and Washington University public health faculty, and directors of both the St. Louis City and County departments of health. The following is a sampling of their feedback on how the current structure affects their work and their visions for the future of our public health departments in the region.

Service Navigation

• An individual involved with a local health center that specializes in services to immigrant populations commented that it is difficult for staff at the health center to navigate disparate systems across the region and said that difficulty was magnified for their clients, for many of whom English was not a first language.

• Several individuals in attendance echoed similar sentiments about difficulties with trained staff trying to navigate services. One individual who works at a faith-based community health agency noted that her staff also had difficulty navigating multiple systems for services. She discussed the fact that her agency’s clients often come from both the city and the county, and nurses often struggled to know which resources were appropriate to refer them to. She went on to suggest there be a system or website that allows service providers to easily understand which services are available to which residents.

Funding

• The leader of a local nonprofit expressed frustration about some programs being heavily reliant on grant funding. A program her organization had partnered with a local health department on did not receive renewed grant funding and as a result the agency was no longer able to serve clients in parts of the region.

• Multiple individuals expressed concern about the proportion of city health department funds that came from grants and contracts. With so much of the department’s budget being tied to federal dollars, it was often hard for their agencies to plan long term and know the program funds would be available to support their mission. Further, many individuals noted the difficulty in setting health department priorities that matched the needs of the community. Rather than aligning resources with the top needs of the St. Louis region, priorities often seemed dictated by the availability of federal grant dollars.

• Individuals throughout the study process repeatedly voiced concerns about not being able to deliver services to individuals in need because of their physical address. One woman who works with homeless populations and individuals who are HIV-positive described instances in which she was unable to provide services to people who would otherwise qualify for her agency’s services because their last address was not in the specified jurisdiction linked to the funding for that program. When sharing this story, others commented on how this reality was in direct conflict with the ideals of public health. Participants were disheartened that distinct and separate funding sources meant that this agency was not able to provide services that would not only help individuals in need but also possibly help prevent the further spread of communicable diseases.

• Three other individuals from different agencies cited similar frustrations with funding sources tied to specific populations in the region. Despite all three agencies having locations in or very near the St. Louis City limits, the agencies were only able to offer a full range of services to a portion of their clients. One person worked for an agency that provides support services to survivors of domestic violence; another worked for an agency providing mental health services to children in foster care; and the third worked to provide mental health services to children from low-income families at an early childhood center. An independent party remarked that these issues related to fragmentation seem to disproportionately affect the most vulnerable among us.

• Professionals with experience with grants – both writing and making – commented that the current structure of separate departments served as barrier to receiving certain grants. They noted that by having two departments, St. Louis City and St. Louis County are likely competing against one another for grant dollars. This was cited as a possible source of confusion for grant-making agencies not familiar with the structure of St. Louis government who might wonder why both the city and county were applying for the same grants. Further, these multiple individuals noted that being able to cite a population of 1.3 million in grant applications would strengthen the region’s position in attempting to obtain necessary funding to support health programs and efforts.

Animal Control

• Two individuals who work for animal welfare agencies discussed that the approaches to animal control in the City and County are very different. St. Louis City does not operate its own animal shelter but focuses primarily on public safety, ordinance enforcement and aggressive dogs and partners with area no-kill shelters for stray animal rescue. The City also has had a treat, neuter and replace program for feral cats in place for approximately three years. This approach was viewed by these individuals as being more “progressive” than that of the County health department. Conversely, a professional familiar with the County animal control practices described their approach as being more concerned with disease control and safety oriented rather than prioritizing animal care. They also noted that because parts of the County are less urban, the range of issues that needed to be addressed through animal control in the county was greater and necessitated a different approach.

Changing Landscape & Public-Private Comparisons

• A common theme that emerged throughout discussions with health care professionals was the changing landscape in public health over the last 20 or so years. Specifically, many individuals pointed out the gradual shift of public health departments’ work, from focusing solely on population-health level services, such as water safety, to a model that also serviced individuals’ health needs. One catalyst behind this shift appears to be the increasing recognition of the impact of individual health on overall health systems. This is particularly salient when considering efforts to treat and contain communicable diseases.

• It was further noted that the landscape affecting public health and health care systems was greatly being impacted by factors like the recent Patient Protection and Affordable Care Act. In particular, two individuals at separate meetings noted the increasing shift of private healthcare and hospital systems to more regional approaches to care. This development was noted as an effort to increase the cost efficiency of service delivery while also improving the quality of care to be more compliant with certain provisions of the Affordable Care Act. The discussion then became one of attempting to understand why the local government’s efforts to address health needs did not mirror that of the private sector. For these two individuals it was seen as almost anachronistic to have a two separate public health departments when most private systems are now operating on a regional basis.

• Closely related, one individual remarked that the presence of two top rated public health schools in the area (Saint Louis University and Washington University) represented a huge missed opportunity for the region. It was noted that successful public health departments in other regions are often “joined at the hip” with local universities in what was considered a mutually beneficial relationship. In Baltimore, Seattle, and Chicago, the public health departments work very closely with public health programs at universities in those cities to increase the capacity of their services while offering unique opportunities for research for those institutions. The largest barrier to forming those types of public-private relationships in St. Louis was seen to be the presence of multiple health departments. Additionally, the individual noted that these types of collaboration in other regions often resulted in opportunities for greater funding for research and services through grants.

Conclusions

Overwhelmingly, the health care and public health professionals with whom we spoke felt there was a need for greater collaboration between the health departments. When asked about the possible benefits of our current structure, all were hard-pressed to think of any and ultimately cited none. Both in group and individual conversations, many people mentioned the combining of the city and county economic development efforts as a positive example of what might be possible for services they viewed as necessarily regional in nature. Their individual and collective frustrations with navigating multiple systems, combined with the mobile nature of disease, led most the conclusion that a more regional approach to public health was necessary to adequately address the needs of St. Louis City and County.

Other Models

While there are certainly differences between the St. Louis City and County departments of health, the recent merger of three health districts in Ohio offer hope that a path forward is achievable. In 2011, three health departments – the Summit County District, the Akron Health Department, and the Barberton Health Department – in Summit County, Ohio, merged together to form the Summit County Public Health (SCPH). According to a 2012 Kent State University retrospective study, the stated goals of the merger were “to enable more efficient service delivery,” “expand public health capacities,” and “improve public health services.” ^[30] Although it is too early to draw robust and definitive conclusions, the study’s authors report “the overall impacts of the consolidation to date are positive in a number of respects…” ^[31]

One of the key goals of the consolidation outlined in the Kent State study was increase in the efficiency of service delivery. Namely, the combining of health departments was designed, in part, to save money. ^[32] Due to the effect of the recent economic downturn on both tax monies and available grant dollars, revenues for the individual departments had decreased in the years prior. After one year of consolidation, SCPH reported a savings of $1.5 million of taxpayer money. With local government contributions totaling just under $10 million prior to the merger, this represents a savings of 15%. ^[33] The Kent State review also notes that these savings are ongoing for the prior taxing districts, as expenses are not currently planned to be increased. Ultimately, the researchers concluded that, “when one compares the financial condition of local health departments in Summit County before and after the consolidation, it seems likely that the consolidation has yielded a financial situation that is improved over what it was in 2010 and over what it likely would have been in the absence of consolidation." ^[34]

A second goal of the consolidation was “to expand public health capacities in Summit County.” ^[35] While it was harder to find conclusive evidence of this goal being accomplished after one year, there seems to have been great progress thus far and the authors assert that “data suggests a growth in potential capacities” and that local health professionals “perceive that improvements in public health capacities are likely to manifest themselves over time as a result of the consolidation.” ^[36] The report attributes this, in part, to basic benefits of a broader pool of human resources. Specifically, it is noted that bringing individuals with varied backgrounds to a single organization allows SCPH to have a greater breadth and depth of knowledge from which to draw. Further, capabilities that may have been a part of one of the previous health departments were now being made available to residents across the county. Despite challenges associated with operational disruptions during the transition, 76% of SCPH staff who were surveyed reported that “they thought the newly consolidated department would yield greater public health capacities in the future.” ^[37]

The third goal of the consolidation was “to improve public health services.” ^[38] Although the Kent State report shows mixed results during the first year of consolidation, most of the SCPH stakeholders interviewed felt services had been maintained and would continue to improve. Researchers attempted to measure both how many services were being delivered and the quality of the services delivered. More people were served in about half of the program areas examined. Of the areas in which service output decreased, some of the decline was attributed to factors external to the merger. For example, the study cites a reported decline in availability of volunteer dentists as a factor in a lower number of dental clients being served. The researchers conclude that “overall, these data appear to suggest that while changes in individual service areas varied, currently monitored public health services as a whole were maintained at roughly the existing levels between 2010 and 2011.” ^[39]

To evaluate the quality of services, the researchers spoke with public officials and stakeholders through interviews, focus groups, and a staff survey. When asked if services had been maintained since the consolidation, 61% of those interviewed or surveyed responded in the affirmative. ^[40] While only 41% of respondents felt services had improved in the first year, an overwhelming 87% felt that the consolidation would have a positive impact on public health services in the future. Considering the scope of the merger and challenges associated with consolidating three agencies, this level of enthusiasm offers great hope for the future of service delivery in Summit County.

Although the St. Louis region and Summit County, Ohio, are not perfect comparisons, the available results of their recent merger offer a potential path forward. St. Louis City and County have a combined population of 1,318,610 while Summit County’s population is 541,824. ^[41] Additionally, their merger consolidated three departments already within the county. Even though there is some overlap between their cultural challenges, our difficulties are different and relate more closely to variation in function and funding sources between the two departments. Despite these distinctions, Summit County serves as a good example of the fact that challenges, big and small, can be overcome. As outlined above, there are many issues that need to be addressed if the St. Louis City and St. Louis County health departments are to consider a different relationship. However, these challenges can be overcome with thoughtful consideration and clear goals. SCPH is an example of where similar discussions, and ultimately greater cooperation, can result in positive outcomes for the delivery of public health services and a potential for savings for taxpayers.

Community-Based Studies

• Public Finance
• Economic Development
• Public Health
• Public Safety : ( Municipal Courts , Police , Fire Protection )
• Parks and Recreation
• General Administration

References

1. ↑ NACCHO, National Profile of Local Health Departments, 11 (2013). Available at: :
2. ↑ Regional Health Commission, “Governmental Public Health Services Study for St. Louis City and St. Louis County” Community Health Infrastructure Assessment, 3 (2005). Available at:
3. ↑ City of St. Louis, Fiscal Year 2013 Annual Operating Plan (2012). Available at:
4. ↑ St. Louis County Department of Health Annual Financial Report to Missouri Department of Health (2012).
5. ↑ St. Louis County, Adopted Budget Summary, 62 (2013).
6. ↑ City of St. Louis 195 (2012).
7. ↑ St. Louis County 13 (2012).
8. ↑ Regional Health Commission 15 (2005).
9. ↑ http://www.stlouiscityrecorder.org/
10. ↑ St. Louis County 176 (2012).
11. ↑ City of St. Louis, Comprehensive Annual Financial Report, 22 (2013).
12. ↑ United States Census Bureau, “State and County QuickFacts” (2014). Available at:
13. ↑ U.S. Census Bureau (2014). Available at:
14. ↑ In additional to FQHCs throughout St. Louis City and County, there are also several other health centers providing care to individuals who are uninsured or underinsured. One such example is Casa de Salud, which caters to new immigrants and refugees who encounter barriers to accessing other sources of care.
15. ↑ City of St. Louis Budget, Public Safety Section, page 183.
16. ↑ City of St. Louis (2012).
17. ↑ St. Louis County (2012).
18. ↑ St. Louis County 176 (2012).
19. ↑ City of St. Louis 195 (2012).
20. ↑ Provided by St. Louis City Department of Health and Hospitals.
21. ↑ Missouri Revised Statutes §205.968
22. ↑ St. Louis County, Rate Book 2 (2013).
23. ↑ City of St. Louis, Assessor’s Office Interview (2014).
24. ↑ St. Louis County Children’s Service Fund website, “Who We Are” (2014). Available at: http://www.keepingkidsfirst.org/WhoWeAre .
25. ↑ Children’s Service Fund website (2014).
26. ↑ St. Louis Mental Health Board website, “About Us- Overview” (2014). Available at: http://www.stlmhb.com/about-us/overview/ .
27. ↑ St. Louis Mental Health Board Financial Statements 16 (2013).
28. ↑ St. Louis Mental Health Board website, “About Us” (2014). Available at: http://www.stlmhb.com/about-us/ .
29. ↑ St. Louis Mental Health Board Financial Statements 16 (2013).
30. ↑ Hoornbeek, John, Aimee Budnik, Tegan Beechey, and Josh Filla. Consolidating Health Departments In Summit County, Ohio: A One Year Retrospective, pp. 28-33 (2012). Available at:
31. ↑ Hoornbeek, et al 37 (2012).
32. ↑ Hoornbeek, et al 2 (2012).
33. ↑ Summit County Legislative Study Presentation, Slide 16 (accessed August 2014). Available at:
34. ↑ Hoornbeek, et al 30 (2012).
35. ↑ Hoornbeek, et al 30 (2012).
36. ↑ Hoornbeek, et al 30 (2012).
37. ↑ Hoornbeek, et al 33 (2012).
38. ↑ Hoornbeek, et al 33 (2012).
39. ↑ Hoornbeek, et al 35 (2012).
40. ↑ Hoornbeek, et al 37 (2012).
41. ↑ U.S. Census Bureau (2014). Available at: .