Redefining the Relationship between California’s State and County Governments: Creating Healthier Communities through Innovative Collaboration and Financing
|April 3, 2013||Posted by John Connolly under Delivery Systems, Health Financing, Insurance Exchange, Legislation/Policy, Medi-Cal, Public Coverage, State, State Budget||
California is the most populous and perhaps the most diverse state in the nation. To accommodate the needs of its different communities, the state relies on its 58 counties to administer many public and social services. The State formally realigned responsibility for administering certain public programs from the state to the county level in 1991, and again in 2011. Programs realigned in 1991 include public health, indigent health, and mental health—with the State dedicating revenues from a portion of the state sales tax and vehicle license fees to support the counties’ administration of these programs. Programs realigned in 2011 include incarceration for low-level offenders, juvenile justice, substance abuse treatment, and additional mental health services—again with associated state revenue streams.
Delegating responsibility to a more local level of government to perform certain functions and deliver social services is crucial to many state agencies because of the greater proximity that county government has to the communities served. By placing the locus of public administration of services closer to communities, the State can facilitate innovation and increase accountability by making the agencies responsible for programs more easily identifiable to the public and the Legislature, thereby improving oversight of effectiveness and efficiency.
Yet, in this arrangement, the State must actively establish clear lines of responsibility, define performance standards, and exercise necessary oversight to ensure accountability. While counties may design programs differently to tailor them to local needs, the State must ensure transparency with regard to county programs’ performance and facilitate knowledge transfer from successes in certain counties to other counties. In the absence of these essential state-level functions, wide variations in the effectiveness of operations and the quality of services can develop, which can result in unacceptable inequities, particularly among vulnerable populations.
This paper examines these issues and proposes policy strategies to increase effectiveness, efficiency, innovation, and transparency. The paper contains four sections that cover different program areas: public health; indigent health; county social services offices and program enrollment; and mental health, substance use, and corrections and community reentry programs. The recent 2011 Realignment, the potential restructuring of existing 1991 health Realignment relationships, and the ongoing implementation of the ACA provide an opportunity to enact many innovative administrative and fiscal relationships that could maximize the positive impacts of both Realignment and the ACA. This rapidly changing policy landscape presents a substantial window of opportunity to improve safety net services, with the potential to make lasting improvements in the quality of life in communities across California.
 Legislative Analyst’s Office. 2012. Available at: http://www.lao.ca.gov/handouts/crimjust/2012/Completing_Juvenile_Realignment_03_22_12.pdf