Two years into the COVID-19 pandemic, Bexar County spent millions in federal pandemic relief dollars on public health programs — with the goal of getting more involved in preventative health, preparing for future pandemics and addressing longstanding health inequities.
Now, the funds are expiring at the same time the county budget is being squeezed, raising uncertainty about the future of the county’s public health department, particularly its newly created Preventative Health Division.
Created in 2022, the division now operates a $10 million annual budget, including 28 staff positions and programs supporting victims of domestic violence, elder abuse and other public health initiatives, according to a county budget document.
Given the budget picture, some county commissioners are suggesting combining county efforts with University Health’s Public Health Division, which was also established that year with the help of temporary American Rescue Plan Act (ARPA) funding.
Former Bexar County Judge Nelson Wolff, who championed the project, said in an interview that he wasn’t sure if the county’s preventative health campaigns had been effective — or what the division had done since he left office.
“I don’t know whether they’ve done any good with it or not,” he said. “Maybe just another bureaucratic department, as far as I know, and if that’s true, then there’s no need to have it. But if they have done some good things and they can be transferred over to University Hospital, then that ought to be done.”
Connecting the dots
The pandemic highlighted longstanding social inequities in Bexar County: poorer ZIP codes with higher rates of diabetes and obesity faced higher death rates from COVID-19 compared to more affluent areas.
In 2022, county manager David Smith and Wolff noted their frustrations of not having expertise within county staff that they could rely on during the pandemic.
Preventive health programs, like health education campaigns, vaccine drives, environmental safety and health screenings, had largely been left to the city Metropolitan Health District (Metro Health) and local nonprofits. But these San Antonio-based resources often didn’t reach residents in unincorporated Bexar County.
With $60 million in ARPA funds set aside to expand public health services in spring 2022, the county had the opportunity to play a larger role in public health and prevention efforts, and the idea was to work closely with University Health, Metro Health and health-focused nonprofits to pursue common goals without duplicating efforts.
That’s when the county established the Department of Preventative Health and Environmental Services, an umbrella department that absorbed existing county functions like animal control and behavioral health, as well as establishing the brand new Preventative Health Division.
Commissioners also voted to allocate ARPA dollars to University Health, the county-owned hospital system, so it could set up its own Public Health Division, which operates separately from the county.
Around $2 million in annual funding was approved for the county’s new Preventative Health Division.
But county leaders seemed to be on different pages regarding the focus of their new health division.
Wolff was keen on the division promoting healthy eating and exercise, like requiring restaurants to include calorie and nutrition information on their menus, and running TV ads on the danger of excessive sugar consumption from soft drinks — efforts he said never made it over the finish line.
“It’s been a big critical issue to me for a long time,” Wolff said. “People are killing themselves. It’s the tragedy of our community. … They can so easily help themselves without a major change, but it takes a lot of pushing and a lot of effort.”
Commissioner Tommy Calvert (Pct. 4) said that he wanted to see the division focus on the social determinants of health such as housing, education, infrastructure, racism and the environment, like pursuing grants to help local businesses reduce greenhouse gas emissions.
“The court has not connected the dots yet on how those should be driven through the funding of a public health division,” he said at the time.
Smith said the goal was to create a “more robust, rapid and coordinated response” to the next pandemic by putting existing public health functions under one roof.
He also cited maps of health inequities in San Antonio — which largely follow economic and racial lines — and reducing such inequities as the driving force behind the county’s efforts.
County leadership said the division would evolve based on input of its new leader, Andrea Guerrero, who oversees the entire Department of Preventative Health and Environmental Services.
Now, the county may have to make cuts to programs and staff in the Preventative Health Division, which has largely relied on ARPA funds.
“We are now going through a review and analysis of all the ARPA positions, and one of the difficult discussions that will be had in this time period is what positions will remain,” Bexar County Judge Peter Sakai told the Report in early July after his budget town hall.
Aside from those positions, Sakai and the county budget-writers at that event said their finances are overall relatively “healthy” for the time being.
“[But] Public Health is actually a brand new department that [Wolff] and the previous court created, and we’re having the discussion in regards to what delivery of services we want our public health department to focus on,” Sakai said at the time.
What the division does today
Since its inception, the division has expanded beyond its original dietician, nutrition specialist and administrative staff to add a population health data manager, public information officer and more than a dozen domestic violence case managers.
The staff shares office space with other departments in the county’s annex building downtown. The building, at 203 W Nueva Street, was considered for demolition but was instead renovated for $8 million in 2022, in part to make space for the new Preventative Health Division.
Much of the division’s resources are focused on public safety efforts, which overlap with public health. Its Safety Team Active Response (STAR) program supports victims of domestic abuse with a team of case workers who specialize in domestic violence.
The division also runs a Senior Justice Assessment Center (SJAC), which aims to prevent and intervene in cases of elder abuse, investigating and reviewing cases of abuse, exploitation and neglect of those 65 years and older.
According to Jennifer Luna, an assistant public information officer with the county’s public health department, the division has also helped fund initiatives for youth and family resilience, healthy eating and exercise, and healthcare access by bringing mobile clinics to the outskirts of San Antonio during the latter half of the pandemic.
It’s not entirely clear how much of the STAR, SJAC and other efforts that fall under the Preventative Health Division still rely on ARPA funding, and whether the programs would need to be axed entirely.
It’s also unclear how much the division is currently involved in more traditional preventative health efforts — like healthy eating and exercise campaigns, or healthcare access improvements — that county leaders described as their guiding mission at the outset in 2022.
The public health director could not be reached for an interview, and Sakai declined to comment further beyond his July remarks. Several county commissioners did not respond to interview requests on the division’s future.
What happens next?
During an Aug. 4 Commissioners Court meeting, Commissioners Grant Moody (Pct. 3) and Justin Rodriguez (Pct. 2) suggested to University Health leadership that some of their ARPA-funded preventative health efforts might need to be picked up by its Public Health Division.
“A public health consolidation between [University Health] and between Bexar County makes a lot of sense,” Moody said. “How can we streamline that and make it more effective and save taxpayer dollars?”
University Health’s Public Health Division is housed at the Vida Clinic on the South Side. The division maintains emergency preparedness efforts, school-based health centers, an emerging infectious disease identification lab, HIV/AIDS outreach, and more.
“We are having to make tough decisions here at the county related to the ARPA dollars coming off,” Rodriguez said. “There are some programs that we established with ARPA dollars specifically in preventative health [and] behavioral health that we’re going to have to figure out a way to put our heads together and continue some of those programs, because they have been impactful.”
ARPA funds expire at the end of 2026, and county commissioners are expected to discuss the future of the preventative health programs in the coming months.
Wolff reiterated that he wasn’t sure if his efforts had paid off, but that he had hoped to meaningfully expand preventative health in San Antonio and reduce the need for acute care.
“It’s the biggest failure that we face as a country and as a local government in terms of trying to address healthcare,” Wolff said. “We do a great job on acute healthcare, tremendous job, but prevention — very little resources go to it.”
