The scene last Friday at the Auburn Public Health Center wasn’t especially dramatic. Just a handful of people, mostly public health workers, waving signs and wearing red shirts that said “these cuts can kill.” There was no yelling, no cops, no tear gas, no rubber bullets. But if the constant bleating of car horns was any indication, the demonstrators' message hit home.
Those fatal cuts, set to take place soon at King County Public Health, would affect the roughly 50,000 people who use the county’s health services, mostly for maternity support, family planning and for the Special Supplemental Nutrition Program for Women, Infants and Children, or WIC. Clinics in Auburn, Federal Way, Greenbridge in White Center and Northshore in Bothell are on the chopping block. Primary care services in Columbia City and Northgate are to be transitioned from the county health department to other care providers. Overall, the cuts would result in more than 200 layoffs.
This has not gone over well.
“There’s a fraction of the population who believes that people don’t need help, that anyone can pull themselves up by the bootstraps,” says Christina Enriquez, who was at the demonstration on Friday and who has been a public health nurse at the Auburn clinic for 29 years. “The truth is, everybody needs a hand up. Everybody needs support. Poverty is not a crime. Homelessness is not a crime. It’s a situation. And communities need to step up.”
Enriquez, a third-generation Mexican-American, does home visits on the Muckleshoot reservation and in Buckley and Enumclaw. She knows what her clients are going through. When she was 12, she and her family were migrant workers in Moxee in Central Washington. Back then, she says, “I didn’t know that I was poor or that I was disadvantaged as a migrant worker.”
But later, she learned how to use the services that public health offered. While she was in nursing school — pregnant and surviving on her student loans — and later as an unemployed single mother, she met with a public health nurse twice a month and depended on WIC. “As a single parent I had no luxury,” she says. “I had no money to buy fresh foods and vegetables. I lived off top ramen and milk until I got into WIC. I’ve used all these services. I know what it’s like to go hungry, I know what it’s like to be isolated and need a friend.”
Handling King County’s current budget bungle is Interim King County Public Health Director Patty Hayes, who assumed the head post just a few weeks ago, after Dr. David Fleming stepped down. After helping more than 165,000 King County residents sign up for the Affordable Care Act, Fleming said in a statement that he had come to the realization that “my personal plans and needs don’t allow me to make the long-term leadership commitment that this organization now requires.”
Now Hayes has to do the dirty work of balancing a $365 million budget that currently faces a $15 million shortfall per year for the next two years. It’s a situation that has no winners, just different shades of losers. And there appears to be no magician pulling money out of a hat to save the day.
According to a post on the department’s website, King County Public Health’s budget woes began 14 years ago, growing out of two voter-approved initiatives in two years. The initiatives, both sponsored by Tim Eyman, were I-695, repealing the motor vehicle excise tax and I-722, capping state and local property taxes that had previously helped fund public services (both measures were overturned in court but legislators later approved key features of the initiatives).
Public health has had increasing financial troubles over the past decade for a variety of reasons, including the recession and a budget unable to keep up with inflation and rising labor costs. More recently, federal payments for Medicaid patients have been steadily declining for the past several years, effectively halved, from $14 million in 2008 to $7 million last year.
Making the puzzle more complicated are grants, levies and fees dedicated toward specific programs, such as restaurant inspections, emergency medical services, jail health services and programs to help the homeless. It turns out that just a small fraction (around $40 million) of the $350 million budget can be used to subsidize clinic operations, where the cost of providing service is outstripping revenue.
Public Health has been able to make things work over the years, staying afloat by “creating efficiencies, spending one-time reserves, securing outside grants and special funding, and reducing staff – including a major round of layoffs in 2009," according to the post on their website.
The Band-Aid approach wasn’t beautiful, but it worked. Until now.
“It all hit like a perfect storm,” said Hayes.
King County Executive Dow Constantine is finalizing his budget, which will be presented to the King County Council in late September, meaning Hayes has few precious weeks to figure out how to mitigate the damage and transfer services to other entities. She’s been making some progress.
At the Northgate clinic, public health is working with Neighborcare, which had already planned to close down its Greenwood facility to take over public health’s primary care facilities in Northgate. Hayes said that they just have to speed up the process now. In Columbia City, they are in talks with Neighborcare and Harborview/University of Washington Medical Center to transfer services. In Auburn, Hayes said they are talking to the Muckleshoot Tribe to preserve a satellite clinic on their reservation.
But in South King County, which has one of the highest poverty rates and where the county’s maternity support services and WIC serve some 32,000 women and children, there is no alternative plan yet. If the cuts go through as planned, the county’s public health clients there will have nowhere else to go. “It is devastating and we recognize that,” Hayes said about the clinic cuts. “That’s why we’re working hard to figure out something.”
Hayes has met with the Federal Way city council and mayor and plans to meet with Auburn officials soon. Federal Way’s council has come out against the cuts, asking King County to reconsider the proposal. At the moment, that seems like the lone option since, according to Hayes, Federal Way and the other local governments affected by the cuts are strapped for cash.
“The current proposal leaves an area of great need completely unserved,” says Federal Way Mayor Jim Ferrell. “The Federal Way and Auburn clinics serve 24,000 poor women and infants who have nowhere else to go. As someone who was raised by a single mother, I cannot accept that the County’s best proposal is to abandon these low-income moms and their kids.”
If the worst-case scenario happens, the nearest clinic for Federal Way and Auburn clients would be Kent. Even if the clinics in Kent were able to absorb the influx of clients, getting to the clinic might prove difficult for low-income people forced to rely on an unreliable transit system. “I don’t know if you’ve ever seen a single mother carry a stroller and two kids onto the bus, but it ain’t easy,” said Hannah Welander, a former public health nurse and a representative for the Washington State Nurses Association (WSNA).
The WSNA leadership, which has been organizing the public demonstrations every Friday, is also visiting with communities to try to figure out alternative funding sources. However, like Hayes, they are also just beginning these conversations, and no silver bullet for the problem has been found. Welander said the organization plans to approach the Washington State Legislature, but fears lawmakers might be preoccupied with the McCleary decision. (The Supreme Court mandate requires the state to fully fund public education, which means coming up with billions of extra dollars.)
The outlook for the county’s public health services may be grim, but Christina Enriquez isn’t giving up. “We have not had stable funding [for health care], and that should be a right,” says Enriquez. A right that she is prepared to keep fighting for.