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The Connecticut Department of Public Health has actively encouraged towns across the state to join regionalized health districts in an effort to simplify the enforcement state laws and regulations, to professionalize staff, improve the availability of services, and further a unified approach public health problems.
The towns of Essex and Westbrook have bucked that trend, opting instead to maintain local independent services.
“The health department is responsible for health outcomes, and the health outcomes in our state are in the top five in the country, but we do have pockets of very poor health outcomes in our cities,” Needleman said. “Regionalizing would be the solution for the city, but I didn’t agree because we had top outcomes and going ahead and regionalizing might bring down our health outcomes.”
“From the state’s point of view, dealing with 169 independent health directors is kind of a nightmare if there is an emergency, and I understand why the commissioner had that problem and pushed health district regionalization,” said Norm Needleman, first selectman of Essex, by phone on Thursday. “But also, there is the issue of health outcomes.”
From Needleman’s perspective he has not seen any evidence that town residents’ health outcomes or services would improve if Essex joined the Connecticut River Area Health District (CRAHD).
“The health department is responsible for health outcomes, and the health outcomes in our state are in the top five in the country, but we do have pockets of very poor health outcomes in our cities,” Needleman said. “Regionalizing would be the solution for the city, but I didn’t agree because we had top outcomes and going ahead and regionalizing might bring down our health outcomes.”
Needleman is not convinced that regionalizing would provide the two things that he looks at when making a decision for his town: cost saving and improved outcomes.
In fact, Essex pays just one additional dollar per capita than its neighboring towns in CRAHD — $15 per capita compared with $14 — said Needleman, and the town’s health director provides additional programs which are not offered by CRAHD.
Rats, asbestos and mosquitoes
It was a loss of personnel that prompted the Town of Stonington to adopt a regionalized approach in 2017 when both the town sanitarian and public health official decided to retire that spring. That put the town in a position of needing to find a solution quickly, said First Selectman Rob Simmons by phone Thursday.
“It was a double whammy. We had to scramble around very quickly and we compared several options — one was to replace existing personnel and the second was to go to a health district format. We decided to do the latter and it saved us money at the beginning” — Stonington First Selectman Rob Simmons
“It was a double whammy. We had to scramble around very quickly and we compared several options — one was to replace existing personnel and the second was to go to a health district format. We decided to do the latter and it saved us money at the beginning,” Simmons said.
The town joined Ledge Light Health District on May 1, 2017, right before an outbreak of rats in Pawcatuck — a small crisis that prompted Simmons to contact Stephen Mansfield, director of Ledge Light.
“I called Steve Mansfield and said we have an emergency. He sent over a half dozen sanitarians, they did door-to-door education, and Ledge Light created an online training program,” Simmons said. “Ledge Light did an incredible job. We could not have handled it with our previous staff. We just didn’t have enough people to do it.”
Simmons said Ledge Light also brought in a higher standard of inspection for food establishments.
“That is very good for our community, though some people have complained about it, but the Town of Stonington is a tourism town with 155 food establishments, from five star to fast food,” he said. “We can’t afford to have an outbreak of salmonella or food-borne disease. We have to be top of the line with food inspections. Ledge Light can handle that level of work and they’ve done an excellent job.”
This year two factories collapsed in Pawcatuck — the Stillmanville Mill in April and a factory building at the Threadmill complex in July.
“The buildings have asbestos and hazardous material. Ledge Light has the depth of expertise to provide us with up-to-date information on the health impacts,” said Simmons.
In late August, mosquitoes in Stonington, North Stonington and Voluntown, tested positive for Eastern Equine Encephalitis (EEE), a rare disease caused by a virus transmitted by mosquitoes. Ledge Light raised public awareness of the issue, said Simmons.
“Steven Mansfield has coordinated messaging to our community, how to take precautions — it’s very important,” Simmons said.
A solution to a state mandate
Joining Ledge Light saved Stonington about $50,000 annually, because otherwise the state would have required the town not only to hire a new sanitarian, but also to replace the part-time health official with a full-time director, said Vincent Pacileo III, director of administration for the town, by phone Friday.
Other towns also saw savings, including Old Lyme, which narrowly voted 82-79 to join the regional health district in 2016. In the last year, the town paid $55,345, for a savings of about $105,441.
The new hires would have cost local taxpayers about $185,000, including benefits, said Pacileo. Prior to that, the entire sanitarian department budget had been $156,000, including salary, benefits, workers’ comp, pension, payroll taxes, auto expenses, training, education, and overhead such as furniture and equipment.
Pacileo said the savings took into account the $25,000 that Stonington’s town sanitarian collected in licenses and inspection fees charged annually to businesses, including restaurants, daycare centers, group homes, and hair and nail salons, as well as for permitting new septic systems — revenue that was lost when the town joined Ledge Light.
The Town of Stonington paid Ledge Light $135,470 the first year, $137,438 for fiscal 2018-19 and $137,030 for fiscal 2019-20, he said.
Other towns also saw savings, including Old Lyme, which narrowly voted 82-79 to join the regional health district in 2016. In the last year, the town paid $55,345, for a savings of about $105,441.
Choosing local control
A decade ago Westbrook, like Essex, made the decision to remain independent.
“It was a very high profile decision Westbrook had to make, and we had a referendum to go to a health district that we voted down 2 to 1,” said Westbrook First Selectman Noel Bishop. Most residents were concerned that regionalizing would lead to uncontrollable fees, make it more difficult to see someone in person and increase response time to emergencies,” Bishop explained.
“You have so much more flexibility when you have the staff here. If we see a need we don’t have to get approval from outside of our district” — Westbrook First Selectman Noel Bishop.
Apart from more control over cost, both Essex and Westbrook pointed to direct involvement and engagement between their health director and stormwater management, water pollution control authorities and planning zoning commissions as important reasons to maintain in-town departments.
“Our health director needs to be constantly interacting with planning and zoning, almost all our projects require sewers,” Bishop said. “You have so much more flexibility when you have the staff here. If we see a need we don’t have to get approval from outside of our district.”
A lack of qualified staff
Towns opting to remain independent face a difficult challenge in hiring qualified staff.
“I was shocked when we were trying to hire the former CRAHD health director, we got just two applications,” said Carl Fortuna, first selectman of Old Saybrook, which belongs to CRAHD.
“In our field we are facing a workforce development crisis. There are not enough sanitarians in the state to move up and be qualified and knowledgeable enough to be health directors” — Sonia Marino, Health Director, Westbrook
According to Sonia Marino, the health director for Westbrook, the tight market for health professionals in the region is due to a combination of a lack of interest, a lack of needed training, and new Federal Department of Agriculture rules that make it more challenging to obtain food inspector licenses.
“In our field we are facing a workforce development crisis. There are not enough sanitarians in the state to move up and be qualified and knowledgeable enough to be health directors,” Marino said.
It’s a particular challenge, she explained, to find someone capable of working in a towns that rely primarily on septic systems.
“Cities are so different from small towns. Directors there spend most of their time dealing with lead stock and inspecting lots of restaurants versus monitoring septic as I do. The skill set is just different,” Marino said. “It’s also hard to explain how to get into the field. You have to take the environmental training courses so you know what you’re doing.”
It’s a problem that Westbrook is handling with on-the-job training.
“I asked to hire someone part time so I could train them and then they can move on to a full-time job,” Marino said. “It’s always been the local departments who train sanitarians and we are losing that.”
District-wide flat fees
For fiscal 2019-20, Ledge Light charged towns $7.37 per resident based on the latest census data provided by the State Department of Public Health, said Mansfield.
According to Ledge Light’s web site, the district serves a population of more than 155,000.
Mansfield said charging a flat per-capita fee makes sense even if town by town needs differ greatly. Ledyard, for example, has fewer food establishments than the Town of Groton, which creates a lower burden on the district’s staff who do restaurant inspections. But Ledyard is primarily served by on-site septic systems, which create a higher burden for the district’s land-use professionals.
“Some municipalities require lots of service in one area but very little in the other and it’s not consistent across the board,” he said.
Over the last decade, the costs have remained remarkably constant. In fiscal 2008, the per capita cost of membership for towns in Ledge Light was $7.30. That rate rose to as much as $7.60 in 2010, and dropped to a low of $6.85 in 2012 and 2013.
These fees are the main source of revenue for Ledge Light, followed by external grants and contracts, and finally fees charged to businesses. In addition, by state statute the Department of Public Health provides a per-person subsidy of $1.80, a rate which can be adjusted by the governor.
The health district’s diverse population, which includes the City of New London, also benefits Ledge Light’s eligibility for grants and contracts from private foundations, as well as from state and federal agencies, Mansfield said.
“Obviously every time we bring in money through an external funding source it takes some pressure off of our budget so we don’t have to present an increase to our municipal members,” he said.
Fees for local business
Mansfield said Ledge Light’s board of directors create the fee schedule for local businesses base on a comparison with other health districts’ numbers.
“We did an analysis that lists maybe six or eight fee districts and we did a fee schedule comparison,” he said. “There are differences, some districts have more services than we do, some have less, and some have the categories we have and others don’t.”
“In the big picture even though I do not like paying extra fees, I do understand in terms of public safety why they do what they do and why they’re so strict,” – Heather Rettberg, owner of La Mia Pizza in Old Lyme.
But switching from a town sanitarian to a health district can mean higher inspection and certification fees for businesses.
For Heather Rettberg, owner of La Mia Pizza in Old Lyme, the principle of public safety is important, but paying the fees isn’t easy for a small business owner.
“In the big picture even though I do not like paying extra fees, I do understand in terms of public safety why they do what they do and why they’re so strict,” she said on Friday. “There were no fees before, when the town was doing it — you knew it was coming, three times a year, and now with Ledge Light, I believe there is about a $300 fee, which covers three inspections, and to get ServSafe certified it’s another $250.”
The shop was also required to install a flow-back system to prevent a potential sewage backup — that cost about $500.
In Old Saybrook, the inspection fees didn’t change when the town switched to CRAHD, said Evan Nguyen, owner of Lovely Nails in Old Saybrook, who had his framed CRAHD certification hung on the wall adjacent to the front desk.
“We had to pay when the town did it — we paid about $10 per workstation –and we pay the same,” he said. The shop has three manicure, three pedicure stations, and a private space for waxing.
Nguyen said he had no problems with CRAHD. “We’re doing fine with them,” he said.
Ledge Light’s land use fees range from $25 to $155 for services such as soil testing, a septic plan review and a wastewater disposal system review. A yearly license for a food service vendor costs between $205 to $280. A food service plan review costs $300. Qualified Food Operator training costs $180 per person. Annual licenses for public pools, public lodging and cosmetology businesses cost $100. Inspection fees for day care centers and group homes are $100.
A balancing act
“They provide extraordinary service with great value,” said Mark Nickerson, First Selectman of East Lyme, who said the town joined Ledge Light more than 10 years ago.
“Part of my respect for them is there have been some health issues with a few restaurants… they are respectful of the fact that this is a small business owner who needs some attention but doesn’t need to be shut down,” he said. “That’s a delicate tightrope to walk and they’ve done it with grace” — East Lyme First Selectman Mark Nickerson.
“They go far beyond a staff member who is a sanitarian, which is what a town would do if they didn’t have a health district,” said Nickerson. “They do so much more — they’ve been looking into the tick-borne illnesses, Lyme disease, the EEE thing, they provide free flu shots. There’s so much that they can do on a regional level with the personnel they have that we could never do.”
The health district has been able to find a balance between working with business owners and taking proper action on health issues, said Nickerson.
“Part of my respect for them is there have been some health issues with a few restaurants… they are respectful of the fact that this is a small business owner who needs some attention but doesn’t need to be shut down,” he said. “That’s a delicate tightrope to walk and they’ve done it with grace.”