Cascade County health department budget shortfalls forced cuts, layoffs
Updated Nov. 10 to correct the city’s contribution to $250,000 from $280,000
For months, Cascade County officials have been discussing and cutting the budget of the City-County Health Department.
That restructuring has looked at limiting the use of unsustainable grants, reducing services that aren’t mandated by state statute and eliminating positions.
This year, CCHD has cut about $1 million from its budget and 14 positions through a reduction in force process and about another five through attrition.
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During a June 5 meeting with County Commissioners and Abigail Hill, county health officer, Commissioner Joe Briggs said, “you’re untying the knot to see what’s grant funded and not. It’s long overdue. It’s painful but it needed to happen and be stronger going out.”
During a June 30 CCHD budget meeting, Briggs said the goal was to spin off grants that weren’t core services.
“We’ve accumulated a group of services that are not central,” Briggs said. “Nobody in this room wants to destroy core services. We’ve got to get out of this other stuff that’s not mandated under us.”
He said they had grants subsidizing core services at one point, but now the core is subsidizing grants.
“We are constantly upside down,” he said.
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Now, County Health Officer Abigail Hill has resigned and her last day is Dec. 5.
Tension over the situation at CCHD was apparent during the Nov. 5 health board meeting, when Jo-Viviane Jones, the longtime family health services division manager, said she was moving up her retirement by six months to February.
During the time allotted on the agenda for the family health services division report, Jones said she wanted to address “crippling” staffing shortages and delayed budget approvals that have inhibited her ability to run her programs.
Her grant is funded by grants, with a county match and Jones said that since the beginning of the year, several abrupt and random changes were implemented to their budget process without communication, training or guidance.
Jones said that they’ve frequently heard comments from county officials that cuts have to be made at CCHD and to have other agencies take on some long standing grants, causing the department to abandon at-risk families and derailing grant opportunities.
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County Commissioner Joe Briggs, who’s also a health board member, asked Jones if she planned to make a staff report.
“I’m seeing a tirade. Would you please wrap it up,” Briggs said.
Jones said she was concerned that services provided by CCHD wouldn’t continue after her retirement and asked the health board to advocate for those programs.
Briggs asked if the comments served as Jones’ resignation to which she replied she’d just given almost four months notice.
Jones’ retirement was mentioned during a June 30 budget discussion between Hill and commissioners.
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Hill was appointed as county health officer in May 2022, serving as the health officer as the county came out of the COVID pandemic and as county commissioners have pushed to “rightsize” the department’s budget.
The position has been posted to the county website and Hill said during the Nov. 5 meeting that they’d received two applications so far.
Hill said she’d asked Briggs and the county attorney’s office to expedite the process and get someone in the position and also for legal to review CCHD and health board operations in the event of a health officer vacancy in terms of what powers can be delegated and to whom.
Briggs said he was still waiting for legal to finish their review but that they’d likely use the same process as when Hill was hired, which was the health board screening applications to forward to the county commission, who with a city commission representative would conduct the interviews and hire.
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In an interview with The Electric, Hill said the health officer’s authority is specified in state law and there’s some question within the county as to how those responsibilities will be covered until a new health officer is hired.
She said in the past, there was an internal second hand person who could serve as interim, but that doesn’t currently exist.
She raised some of those specific issues during a meeting with Commissioners Briggs and Eric Hinebauch on Nov. 6.
Hinebauch asked who would execute the continued budget adjustments and potential further cuts after Hill’s last day of Dec. 5 if a new officer hadn’t yet been hired.
Briggs said that it would depend on hiring, but ultimately, commissioners oversee CCHD and would instruct the adjustments, setting whatever parameters are needed for an interim health officer.
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Hinebauch asked again what the timeline would be since he believed it unlikely they’d hire someone by Dec. 5, but that remains under discussion.
Hill said one thing she didn’t tackle this year was how CCHD does billing for services, such as collecting from Medicare and Medicaid or other insurance companies.
It’s something that cuts into their revenues since the vendor takes six cents on the dollar of what’s collected.
Commissioners said that was something to further look into.
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Hill said her staff was looking for guidance on the transition plan, particularly in the prevention services division, which hasn’t had a manager for awhile and she’d been filling that role.
“They’re wondering who to report to,” Hill told commissioners.
Hill said she was also working with human resources in terms of who was the first call in the case of emergencies such as outbreaks. As health officer, she’s been that first call and she’s salaried.
She said she’d planted the seed of the issue awhile ago but hadn’t made much progress. With her departure, decisions needed to be made for who was the first call. The other salaried employees don’t have medical experience and unions have specifications for on call pay.
Briggs said they’d discuss it.
Hill said that she’s also been serving as the privacy officer since that position was eliminated in the budget cuts and had proposed the county attorney’s office take over that role, but the deputy attorney she’d broached it with is leaving the county on Nov. 7.
As the county is working through those issues as Hill departs the role of health officer, the question of how public health is funded remains.
Put simply, CCHD is funded by two buckets, grants and local government.
Grants have been impacted with federal changes and cuts and the county has been adjusting budgets accordingly, cutting staff and services if the grant goes away. While challenging, it’s a more clear cut process, Hill said.
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“The problem we skirt around is the local government funding. I do not have enough local funding and revenue generating opportunities to fund the health department as it should be funded,” Hill said in an interview with The Electric. “We can’t just keep cutting from what they call mandated services. We have a local funding issue and maybe it hasn’t been talked about enough.”
The city has contributed $250,000 to CCHD, a number that has remained the same for about a decade, with the county contributing about $800,000.
It’s been a point of contention for county commissioners, particularly Briggs over the years, since the majority of citizens and services that CCHD provides are within the city limits.
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The cost sharing of joint operations has caused tension over at least the last decade, as the city shoulders more of the cost burden for the Great Falls Public Library and the 911 dispatch center, but the county funds the bulk of the health department and the entirety of the CodeRed emergency notification system.
Hill said there’s been discussions on the city’s financial contribution and what it might look like going forward, or other options for support that aren’t necessarily direct funding.
Hill said she’s consistently surprised by people who don’t know what the health department does. It often flies under the radar when things are working well, when there’s no outbreaks or a foodborne illness at a restaurant.
“We hope nothing’s wrong, but it takes a lot to make sure nothing’s wrong,” Hill said.
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She’d been hoping that the fall immunization clinics would bring in at least level revenue this year, but those numbers dropped for a range of reasons to include federal discussions about COVID vaccines, marketing and road closures downtown.
It’s been challenging for CCHD staff with many changes to their financial processes this year, but that’s also put them more in line with federal grant requirements.
CCHD is a subrecipient of those federal funds that pass through the state.
Many of those requirements haven’t been looked at or enforced for a very long time,Hill said, but CCHD staff weren’t trained in the past on those processes that can be complicated and nuanced.
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Hill said that the county finance officer brought in a grant training a few weeks ago that many CCHD staff attended, which was helpful.
Hill said she’s “had to advocate for the importance of funding for those services and not to be extreme, but they can be life and death.”
Viruses and bacteria may seem small and quiet, but can be lethal, Hill said, making public health a form of public safety.
“There’s a lot at stake,” she said.
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Leaving CCHD, Hill said she wishes the department the best and “I care so much about public health.”
Hill, a nurse, is going back to school and staying in the public health field.
In October, The Electric sat down with Hill to talk about the budget cuts and restructuring at CCHD this year.
Their grant funding was about $750,000 less this year compared to last year.
Of that, about $450,000 was COVID immunization funding that they knew was dwindling, but the other $250,000 were cut or reduced with little warning.
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Some grants have been backfilled by CCHD funding over years but the direction from county commissioners this year has been to cease that practice.
That lead to staff reductions and discontinuation of some services.
Some will be shifting to other agencies in town, like the Ryan White program, which is HIV case management and prevention. The Indian Family Health Center is taking over that program locally.
Other funds for asthma home visitation and cancer screening programs have been cut, as well as the work site wellness program.
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The non-grant portion of CCHD includes environmental health, which handles inspections of restaurants, tattoo parlors, hotels and more, plus septic review.
Inspections generate revenue, about $200,000, but not enough to cover actual costs and with low staffing in recent years, inspection rates were down to about half of restaurants in 2023, raising concerns about the possibility of foodborne illness.
They’ve since been able to hire more staff and have restored inspection rates, looking at resuming inspections for tattoo shops to potentially generate more revenue.
“Over last year, we had to look at what we had to cut because we’re significantly over budget,” Hill said.
Some positions that were added during COVID, such as the communications specialist, were cut and those tasks have been absorbed by other CCHD staff.
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Eliminated positions include a family nurse practitioner who could do some exams and STI testing; the work site wellness program manager, communication specialist, plus three providers programs, plus three nurses, the WIC director, an emergency preparedness coordinator and partial position in home visits through attrition.
“The work’s not less,” Hill said. “We’ve reduced a lot. I feel like I’ve had to trim a bunch of fat, next is arms and legs. That’s a quarter of my staff.”
They’ve been working to keep grants that are sustainable and looking for other community partners that may be able to take over grants that are less practical for CCHD.
Other larger health departments in Montana have levies to supplement their funding, Hill said, such as Riverstone Health in Billings and Gallatin County. Missoula has some levies and interlocal agreements to split costs between the city and county, Hill said.
“We’re reduced hundreds of thousands of dollars for expenses, and it’s still not okay,” Hill said. “Efficiencies are only going to go so far.”
During the August health board meeting, Hill told the board that they were still working on their budget and grants that were sustainable or not.
Some that had been sustainable for years, such as the cancer grant, now look “very different than it did three years ago.”
It’s a “triple storm” of limited local government funding, shrinking grant funding and the loss of COVID funds, Hill said of their budget. “Ultimately, nothing is easy.”
She said CCHD was working with community partners to see who could pick up some programs and ways to reduce duplication since “a lot of people are losing funding.”
During a June 30 budget meeting, Briggs said he wanted to get the health department down to what it should be and do it extremely well, letting other agencies take over the additional tasks, such as WIC.
“This is a process, not an event,” Briggs said.
Making cuts and restructuring was “never going to be pleasant,” he said.”We’ve just got to get down to where we are right-sized for the real environment we are in. It’s a big problem. This has been ugly and you’ve gotten a lot done.”
