Who pays for public health? Who sets pandemic rules? Idaho changed the law

The 2021 Legislature gave county governments “a lot more oversight” over public health

By: - July 26, 2021 4:30 am
Central District Health sign

Central District Health offices, in West Boise, are the public health headquarters for Ada, Boise, Elmore and Valley counties. (Audrey Dutton, Idaho Capital Sun)

Two bills passed through the Idaho Legislature in the 2021 session that changed how Idaho’s public health districts are funded, and how much authority they have.

State and local governments are now taking up a big question: “What does the future of public health look like in Idaho?” said Seth Grigg, executive director of the Idaho Association of Counties.

With the two legal changes, “counties really do have a lot more oversight over public health districts than what they did previously,” he said.

Moving around the money for Idaho medical care and public health

One bill created a complicated swap in who pays for local public health agencies. It took away state support for Idaho’s seven public health districts and sought to replace that money with savings from other programs.

Most of Idaho’s counties will probably break even on that swap, Grigg said. But some counties, particularly in East Idaho, may need to fill a funding gap for their local health districts.

House Bill 316, introduced by Rep. John Vander Woude, R-Nampa, made a few changes that take effect next March:

  1. It changes who is eligible to have their catastrophic medical bills paid by indigent programs. For many years, Idaho’s taxpayer-funded state and county indigent programs would cover the hospital bills when, for example, a low-income Idahoan needed heart surgery, had a stroke or was injured in a car crash. But now that Idaho Medicaid is open to the state’s working poor, those bills can be covered by health insurance. The bill set in stone that shift in financial responsibility. Idahoans who qualify for Medicaid, or for insurance plans sold on Idaho’s health exchange, would no longer have catastrophic medical bills paid by state and county indigent programs.
  2. That means Idahoans who are uninsured and have a catastrophic medical event would either have to enroll in Medicaid — or be enrolled by their medical provider — or be covered by a private insurance plan. Otherwise, the bill is their responsibility. Grigg said it appears that “just one” group of people would still fall into the indigent category: undocumented residents. “And we don’t have a good sense at this point of what that population looks like” in terms of medical claims, he said. One county estimated that about 25% of their indigent claims were from care provided to undocumented residents, he said.
  3. The bill re-routed tax revenues that would have gone to those indigent programs; it directed the money instead to Idaho’s seven public health districts.
  4. Finally, with the public health districts tapped into a new funding source, the bill pulled the state’s financial support for them.

The bill requires counties to fund their health districts at 2021 levels, Grigg said.

“So counties can’t be like, ‘We’re not going to cover the state’s share anymore.’ They’re required to do that,” Grigg said. “I have a lot of trust in the commissioners, and they know what needs to be done, and they’ll fund it.”

A large share of public health districts’ funds — he estimates about 70% — comes from user fees.

“For most counties, (the change) will be either a wash, or a net savings,” he said.

Russ Duke, director of Boise-based Central District Health, said he doesn’t expect much of a change to his public health district.

“Like any law that goes into effect, in particular where you’re dealing with a major revenue source, ‘will that play out as anticipated?’ is a question,” Duke said.

But for some health districts in East Idaho, the savings from not having to pay indigent claims won’t be enough to offset the loss in state funding.

“We anticipate it’s going to have significant impact on the counties,” said Geri Rackow, director of Eastern Idaho Public Health based in Idaho Falls.

Eastern Idaho Public Health Director Geri Rackow and Dr. Clay Prince, chief medical officer of Madison Memorial Hospital, at a press conference in March 2020.
Eastern Idaho Public Health Director Geri Rackow and Dr. Clay Prince, chief medical officer of Madison Memorial Hospital, announce one of Idaho’s earliest cases of COVID-19 at a press conference in March 2020. (Photo courtesy of EastIdahoNews.com)

Seven of the district’s eight counties historically haven’t paid a lot of indigent medical claims.

The neighboring health district based in Pocatello is “kind of in the same boat,” she said.

Rackow doesn’t know what will happen, as public health goes up against other line items in the county’s budget.

“It’s going to take a couple of years to really see how this plays out,” she said. “But as it stands … it’s going to cost the counties in my health district significantly more than they were paying previously.”

Rackow said the health district has “always had an excellent relationship with our counties.” She hopes they’ll find a way to make up any gaps in funding for public health.

“It’s kind of a wait-and-see, but we are internally doing everything we can to reduce expenses and position ourselves to be as efficient as possible, so that we’re not needing to take more funding from the counties …”

Who gets to decide on public health orders?

Another bill the Idaho Legislature passed in the 2021 session placed new limits on the authority of Idaho’s public health boards.

Senate Bill 1060, sponsored by Sen. Steve Vick, R-Dalton Gardens, gave county commissioners the ability to overrule public health orders within seven days.


Each county in a public health district already has a say in whether to issue orders. They have a seat on the health board and can vote, alongside health professionals, on those decisions.

The bill added another layer of county control.

When a public health board issues a county-wide or district-wide public health order, the commissioners in whatever county the orders affect will vote to approve or deny it, the bill says.

“If the board of county commissioners approves the order, then the order will take effect immediately for a period of 30 days,” it says. “Thereafter, the order may be extended, amended, or modified and reimposed for 30-day periods, subject to approval by the board of county commissioners.”

That means, for example, that Ada County commissioners could cancel the kind of public health orders that Central District Health issued in response to COVID-19 surges.

The CDH board last summer issued orders for Ada County that, for example, forced bars and nightclubs to close due to coronavirus cases the district had traced back to those establishments. The move angered some bar owners — one who later was hospitalized with COVID-19 — but it may have worked. Cases reported to CDH peaked a few weeks later, then fell until mid-September.

Photo of Central District Health Director Russ Duke
Central District Health Director Russ Duke

Reflecting back on those orders, Duke says the complaints and protests against the CDH board’s decisions did not represent the overall public sentiment.

“The good thing is, it doesn’t happen very often — every 100 years, approximately, like with a pandemic,” he said. 

Grigg said that, during the pandemic, most health district boards have made their decisions in conjunction with their counties’ leaders.

“In most cases if the board of county commissioners wasn’t supportive of a countywide change, the districts largely did not make those changes,” he said.

In other words, health boards issued mask mandates and other public health orders in communities where people were most likely to follow them.

One exception was Kootenai County. The Panhandle Health District last fall removed a mask mandate it had issued for Kootenai County, even as local hospitals were full and COVID-19 cases were rising. The mandate had been widely ignored and never enforced by local law enforcement, the Spokesman Review reported then.

“But generally speaking, in most districts, they did not issue a mask mandate without the support of the (counties),” Grigg said. “And then when it came time to lift the mandates, it was generally motivated by the commissioners saying it (was time). And it’s for that reason that I don’t see this (change in the law) as being a big shift.”

Duke said that dynamic was true with the Central District Health board and the four counties within CDH’s jurisdiction.

“We work very closely with all of our counties, and mayors in our counties,” he said.

Without local buy-in, a public health order can be toothless anyway, he said.

County commissioners who didn’t like an order could send a message to their community that the order “does not apply.”

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Audrey Dutton
Audrey Dutton

Audrey Dutton was a senior investigative reporter with the Idaho Capital Sun after 10 years at the Idaho Statesman. Her favorite topics to cover included health care, business, consumer protection issues and white collar crime. Before coming home to Idaho, Dutton worked as a journalist in Minnesota, New York, Maryland and Washington, D.C. Dutton's work has earned dozens of state, regional and national awards for investigative reporting, health care and business reporting, data visualization and more.