Use of fees to fund local public health services in Western Massachusetts.

CONTEXT: Recent budget cuts have forced many local health departments (LHDs) to cut staff and services. Setting fees that cover the cost of service provision is one option for continuing to fund certain activities. OBJECTIVE: To describe the use of fees by LHDs in Western Massachusetts and determine whether fees charged cover the cost of providing selected services. DESIGN: A cross-sectional descriptive analysis was used to identify the types of services for which fees are charged and the fee amounts charged. A comparative cost analysis was conducted to compare fees charged with estimated costs of service provision. SETTING AND PARTICIPANTS: Fifty-nine LHDs in Western Massachusetts. MAIN OUTCOME MEASURES: Number of towns charging fees for selected types of services; minimum, maximum, and mean fee amounts; estimated cost of service provision; number of towns experiencing a surplus or deficit for each service; and average size of deficits experienced. RESULTS: Enormous variation exists both in the types of services for which fees are charged and fee amounts charged. Fees set by most health departments did not cover the cost of service provision. Some fees were set as much as $600 below estimated costs. CONCLUSIONS: These results suggest that considerations other than costs of service provision factor into the setting of fees by LHDs in Western Massachusetts. Given their limited and often uncertain funding, LHDs could benefit from examining their fee schedules to ensure that the fee amounts charged cover the costs of providing the services. Cost estimates should include at least the health agent's wage and time spent performing inspections and completing paperwork, travel expenses, and cost of necessary materials.

Smoke and mirrors: how Massachusetts diverted millions in tobacco tax revenues.

OBJECTIVE: This study examines the politics of appropriating Question 1 tobacco tax revenues in the first budget year after Massachusetts voters passed the ballot initiative in 1992. The initiative increased the tobacco tax on cigarettes by 25 cents per pack and on smokeless tobacco by 25% of the wholesale price. METHODS: Data were collected from newspapers, letters, memoranda, budgets, press releases, legislative floor debates, government documents, legislative journals, personal interviews, and tobacco industry documents that were downloaded from the Tobacco Archives internet site. RESULTS: During the first budget year, programmes mentioned by the initiative that were not exclusively tobacco related accounted for 27% of total Question 1 expenditures, while 50% of the revenues were allocated for programmes that were neither mentioned by the initiative nor provided any tobacco education, prevention, and cessation services. Only 23% of Question 1 funds were appropriated for programmes that provided exclusively tobacco education, prevention, and cessation services. Question 1 revenues were also used to supplant funding for pre-existing programmes, which was explicitly prohibited by the initiative. The first budget year became the template for Question 1 appropriations in subsequent fiscal years. CONCLUSION: Politics did not end after voters passed Question 1. Public health advocates lacked a strategy and budget plan to influence the appropriation of Question 1 funds after the passage of this ballot initiative.

Breaking the alliance: Defeating the tobacco industry's allies and enacting youth access restrictions in Massachusetts.

OBJECTIVES: We describe the tobacco industry's effort in Massachusetts to block the adoption of local regulations designed to reduce youth access to tobacco products. We also explain how state-funded tobacco control advocates overcame industry opposition. METHODS: We examined internal tobacco industry documents and records of local boards of health and conducted interviews with participants in local regulatory debates. RESULTS: The industry fought proposed regulations by working through a trade group, the New England Convenience Store Association. With industry direction and financing, the association's members argued against proposed regulations in local public hearings. However, these efforts failed because community-based advocates worked assiduously to cultivate support for the regulations among board of health members and local community organizations. CONCLUSIONS: Passage of youth access regulations by local boards of health in Massachusetts is attributed to ongoing state funding for local tobacco control initiatives, agreement on common policy goals among tobacco control advocates, and a strategy of persuading boards of health to adopt and enforce their own local regulations.