A Crisis in Tulare Booklet by wuyunyi

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									A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




                                           Table of Contents

   Executive Summary.......................................................................................2

   Tulare: A Growing County ............................................................................4
    Challenges ....................................................................................................5
    The Role of Tulare Government .....................................................................6
    The Government and Improving Tulare .........................................................7

   Tulare: Financial Status ................................................................................8
    The General Fund ..........................................................................................8
    Additional Funding Streams ..........................................................................9
    The Millennium Fund ...................................................................................10
    Creating Positive Changes ..........................................................................11

   Tulare Government: Perpetuating the Problem ........................................12
    Inequitable Wages .......................................................................................12
    Health Insurance Costs ...............................................................................13
    A Quality Workforce Threatened .................................................................17

   Tulare Government Practices: Impact on the Community.......................18
    Public Safety ...............................................................................................18
    Child Protection ..........................................................................................19
    Protecting Consumers ................................................................................20
    Contributing to the Health Care Crisis .........................................................21

   Mapping the Way Forward: County Comparisons....................................22
    Kern County– Investing in the Workforce ....................................................22
    Santa Clara County—Investing Resources ..................................................23

   Working Together Leads to Quality Services ...........................................24
    Community Oversight of Tobacco Settlement Funds...................................25

   Protecting Tulare’s Future ..........................................................................26
    Accountability—Working with the Community ............................................26
    Prioritize Spending ......................................................................................26
    Cooperation and Collaboration ...................................................................27

   References ...................................................................................................29




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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community



    Executive Summary
    The Central Valley is rapidly becoming one of the premiere locations for
    California residents. Tulare County, rich in agricultural resources and land,
    embodies the future for California’s economic and demographic expansion.
    As an area that offers affordable housing and new business opportunities,
    Tulare has the necessary foundation to accommodate the current popula-
    tion boom, which brings with it promises of dynamic economic growth and
    demographic diversity.

    The growing pains of expansion, however, require an increase in public
    services. Tulare residents rely on their leaders and county workers to im-
    prove infrastructure, provide quality public health care, protect the public,
    and deliver critical social services to those in need. County leadership
    needs to provide businesses with opportunities to grow, while protecting
    consumers through rigorous inspections of Tulare’s growing commercial
    and agricultural industries.

    The reality is Tulare is facing a growing crisis. The poverty level continues
    to rise, and coupled with increased air and ground water pollution, dire en-
    vironmental conditions are leaving an alarming number residents, espe-
    cially children, sick and in need of quality care.

    As a result of the spending priorities of the County leadership, the crisis is
    exacerbated by a lack of funding for critical services. Inadequate funding
    for these services has resulted in a workforce that’s feeling the strain of de-
    livering quality services and programs for residents.

    The Board of Supervisors’ refusal to invest sufficiently in critical social and
    economic programs and workforce is stifling Tulare’s opportunity to estab-
    lish itself as a leader in the Central Valley. While Tulare County’s budget
    has amassed surpluses over the past few years, spending on important
    programs has decreased.

    As the largest employer in the community, the Tulare County government
    has a history of paying low wages while charging increasing health benefits
    costs to its public workforce. At the same time, salary and benefit increases
    for county leadership and management are commonplace. It is no wonder
    that the public workforce falls further behind surrounding counties.

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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




    This report provides ample evidence that the county can demonstrate its
    leadership role by improving funding for public services and by paying equi-
    table wages and benefits. By continuing to undervalue public services and
    its employees, the county risks having a safety net that is becoming frayed
    and broken, due to high turnover and excessive low morale.

    To improve the conditions of Tulare County and to ensure future prosperity,
    the Board of Supervisors should follow the examples of Tulare’s counter-
    parts in nearby counties: Rededicate resources into the public workforce
    and public services. That are the foundation of every prosperous
    community.




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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




  Tulare: A Growing County
  The population of Tulare County has grown steadily over the past two
  decades as tens of thousands of new residents migrated to the county from
  across the state and around the world. Both residential and commercial
  development of land has increased to keep pace with the new residents. As
  a result, existing communities have expanded and there are plans for the
  development of entire new communities. The impacts of these changes
  are being felt across the Central Valley and the state. Projections indicate
  that Tulare will continue to experience a high rate of growth and the number
  of residents will more than double to over 1,000,000 people by 20501.
                                                                               Projections indicate
                                                                                  that Tulare will
                                                                                    continue to
                                                                                experience a high
                                                                                rate of growth and
                                                                                  the number of
                                                                               residents will more
                                                                               than double to over
                                                                               1,000,000 people by
                                                                                       2050.
  Tulare has historically been an agricultural region. It is the second-largest
  agricultural producing county in California, with leading commodities such
  as milk and other dairy products, oranges, cattle, and grapes2. While
  agriculture remains the largest sector in terms of total jobs, its dominance in
  the social and economic life of the county is beginning to decline.

  The high rate of population growth means that Tulare will capture an
  increasing proportion of the state’s population. Coupled with the growth
  and diversification of the local economy, Tulare is expected to assert
  greater influence in the state, both economically and politically. Yet, the
  future of the county and its great promise is threatened by the County’s
  failure to confront and solve the myriad of economic and social problems it
  currently faces.


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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




  Challenges

  Tulare ranks among the lowest of all counties in some of the most
  important social and economic measures that determine the health of a
  community. Tulare County has one of the highest unemployment rates,
  highest poverty rate, and highest child poverty rate of any county in
  California3. In 2000, almost one in four residents was living in poverty4.

                                                      The County is also in the midst of a health
     The county has                                   care crisis. The county has consistently had
  consistently had one                                one of the highest rates of uninsured
   of the highest rates                               residents in the state. One in five Tulare
       of uninsured                                   County adults lack full-year health
                                                      insurance5. Most premature deaths in the
  residents in the state.                             county are due to chronic conditions that
    One in five Tulare                                could be prevented if residents have access
    County adults lack                                to regular screenings and care by a
     full-year health                                 physician and affordable prescription
                                                      medications6.     Unfortunately, too many
        insurance.
                                                      residents do not have the means to receive
                                                      necessary care without access to affordable
                                                      health insurance.
  The crisis has been further exacerbated by the closure of major health
  facilities. This has created a health care delivery system that is
  overstretched and under-funded7. The county has too few health care
  facilities, even as the number of residents continues to increase, resulting
  in a shortage of hospital beds, doctors, nurses and other health care
  providers8.

  Finally, these dire conditions are further complicated by the region’s serious
  air and ground water pollution. Tulare County is ranked 5th nationally as a
  top ozone polluting county in the country9. From 2005 to 2006, the total
  number of high ozone days increased by more than a month, from 229 to
  26310. Ground water contamination is widespread throughout the county
  and is so serious that many residents are forced to drink expensive bottled
  water, rather than the water from the tap11.




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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




  The Role of Tulare County Government

  The County is the primary body responsible for developing policies that
  facilitate the growth and development of the county.             The County
  determines the type and level of funding for public services provided to
  residents and businesses. Furthermore, state law mandates the County as
  the primary safety net provider for public health care, social, and other
  services. Yet, the reality is that existing services are being strained in the
  face of demands placed by a growing community. Unless the county can
  accommodate growth in a sustainable manner, the quality of life, environ-
  ment, and basic services will be negatively impacted.

  Tulare is not only an important service
  provider but also the primary employer in                                           The County
  the community. The County workforce is                                              workforce is
  approximately 4,600 strong, making it the
  largest employer in the county 12 .
                                                                                 approximately 4,600
  Employees provide a wide range of public                                       strong, making it the
  services working in programs such as                                            largest employer in
  health services, resource management, and                                           the county.
  consumer safety services.
                                        Health and Human Services

  Employees working in Health and Human Services provide a safety net and
  other social services to county residents. As part of the County’s
  state-mandated obligations, the County operates four health care clinics
  and provides funding to reimburse private hospitals that provide charity
  care to low income residents.

                                            Resource Management

  Employees working in Resource Management play an important role in
  supporting Tulare County’s quality of life and economic prosperity by
  managing development and protecting the natural resources of the
  community. The department is responsible for planning future residential
  and economic development in the county, enforcing local and state laws
  and regulations, and planning the maintenance of roads, parks and other
  public facilities.
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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




           Agricultural Commissioner/Sealer of Weights and Measures

  Employees working in the Agricultural Commissioner/Sealer of Weights and
  Measures department provide regulatory oversight over agricultural and
  consumer products. The department is responsible for conducting quality
  control inspections related to crop health, food safety, and fair business
  practices. Department employees provide training to local farmers and the
  community and assist farmers by sharing best practices.


  The Government and Improving Tulare

  As the largest employer and major provider of public services, Tulare
  County plays a pivotal role in the economic and social health of the
  community. This fact has not escaped those that worry about Tulare’s
  future.    Over the past several years, residents, community based
  organizations and local businesses have become increasingly aware that
  the County Board of Supervisors must wake up to the problems and plight
  of the people. Elected officials must be ready to make bold, effective deci-
  sions about funding, programs, staff and infrastructure which are necessary
  to build for the future.




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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




  Tulare: Financial Status

  For several years, Tulare County has claimed poverty as a reason for its
  inability to invest resources in critical public services. Nevertheless, a
  review of recent financial documents, spending priorities, statements made
  by elected officials and top management, and an analysis of the county’s
  long-term growth projections, demonstrate otherwise.

   Since 2005, the                              The General Fund
  County’s General
    Fund balance                                Despite current economic weakness across the
                                                state and the nation, the County has indicated its
    has increased                               ability to withstand economic hardship and
   more than 35%,                               maintain long-term financial health.       Recent
     meaning the                                population and economic growth has significantly
      county has                                improved the County’s financial health (Figure 1).
                                                Total revenues available to fund public services
     significantly                              exceeded costs during this same time period,
   more resources                               resulting in annual budget surpluses. Since
    to fund public                              2005, the County’s General Fund balance has
    services than                               increased more than 35%, meaning the county
                                                has significantly more resources to fund public
   previous years.                              services than previous years13.

  Furthermore, the amount of surpluses generated annually increased from
  $4.4 million in 2005 to $7.3 million in 2007, reaching $60 million total in the
  General Fund in 200714. While revenues and surpluses increased, the
  County’s outstanding debt continued to decrease. In addition, Tulare
  County had one of the lowest levels of debt when compared to nine
  neighboring counties and the City of Bakersfield.
                                                    Tulare County General Fund Balance


                                     $60,000,000
                                     $50,000,000
                                     $40,000,000
                                     $30,000,000
                                     $20,000,000
                                     $10,000,000
                                              $0
                                                      2003          2004          2005          2006          2007



                              Figure 1. The General Fund balance has increased 35.1% since 2003. Source: Tulare County CAFRs.



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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




  Additional Funding Streams

  The improved financial health of the county coincides with financial
  practices that limited funds to key public services. An independent
  consultant from Harvey M. Rose Associates, a public sector management
  consulting firm based in San Francisco, found additional sources of
  revenue that are available to supplement the General Fund15.


  Surplus cash balances in the Risk
  Management Internal Service Fund.
                                                                                      “We’ve been as
  The county maintains two internal service                                           healthy as we’ve
  funds, one to pay for insurance costs and a                                       ever been…we feel
  second to pay for central county services                                          that we can cover
  such as the mailroom, utilities, telecommu-                                       next year’s budget
  nications, and custodial/maintenance ser-
  vices. These funds combined had an                                                and maybe cover a
  unrestricted cash balance of $10.1 million,                                         little bit of state
  and the insurance fund had a funding level                                             reductions.”
  of 133%. Although actuaries generally                                                Tulare County
  recommend that agencies maintain assets
  significantly greater than their actual
                                                                                       Administrative
  estimated liability, such dedicated reserves                                              Officer,
  are not required and not maintained by                                             Jean Rousseau16.
  large and highly rated counties in California.


  For example, Santa Clara County only maintains insurance reserves equal
  to the county’s estimated liabilities. Other large agencies such as the City/
  County of San Francisco and Los Angeles County, account for insurance
  claim costs in the annual budget on a pay-as-you-go basis, without
  maintaining separate and dedicated reserves in an internal service fund.
  For this reason, the county could return the excess balance to the funds
  from which they were obtained, namely the General Fund.




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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




  Surplus cash balances from the Redevelopment Project Area Special
  Revenue Funds.

  If the County has provided any advances from the General Fund or
  incurred any expenses related to the County Redevelopment Agency,
  surplus property tax increment revenue in redevelopment funds may be
  used to reimburse the General Fund. These funds have up to $546,000
  available for reimbursement.

  Surplus cash balances in special revenue funds that are often part of
  or subsidized by the General Fund.

  The 2007 Comprehensive Annual Financial Report (CAFR) showed Tulare
  County as having 24 non-major special revenue funds. Three of these
  funds, the Library Fund, Structural Fire Fund, and the Flood Control Fund,
  are substantially financed from property taxes. Each of these funds had
  significant unreserved/undesignated fund balances at the end of Fiscal
  Year 2006-2007. As each of these functions is often considered a General
  Fund activity in other counties, these funds totaling approximately $6.0
  million, could be removed and the balance transferred to the General Fund,
  unless restricted by any special district or the County Ordinance Code.

  The Millennium Fund

  The County also receives over $4 million dollars annually in health care
  related funding that the county diverts for other purposes. In 1998, the
  Attorney General’s of eight states including California, settled several
  lawsuits pending against the tobacco industry. The tobacco settlement
  funds were intended to compensate states for the health-related impacts of
  smoking, and required tobacco companies to make payments to the states
  in perpetuity. The Legislative Analyst’s Office projected that California
  would receive an estimated $25 billion through 202517. This money would
  be split between California’s 58 counties primarily based on population.
  Tulare County was estimated to receive $118 million over those 25 years18.

  Contrary to the purpose of the settlement, Tulare County leaders chose to
  sell the payments for an upfront sum of $45 million19. County supervisors
  placed the money into an account, called the Millennium Fund, earmarking

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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




  the resources for infrastructure projects including roof repairs, backup
  generator replacements, and building renovations.

  Numerous community members and organizations publicly rejected this
  decision. The Tulare County Tobacco Settlement Coalition, a coalition of
  hospitals, health clinics, and disease prevention groups, argued that the
  funds should be used to help with what they call the “appalling health
  conditions in Tulare County”20.

 Creating Positive Changes

  The financial analysis reveals                            “Tulare County is financially
  that Tulare County is in a                                sound,” says Allen Ishida,
  position to create positive
  economic and social growth in                             Tulare County Board of
  the Central Valley.                                       Supervisors21.

  As the largest employer in the area with resources to invest in public
  services and the county workforce, Tulare leadership has the ability to
  accommodate population growth and stimulate the economy. The county
  should reconsider its financial practices and develop a system that more
  clearly supports the community and employees while maintaining a sound
  reserve for contingencies. It will also be necessary for the County to
  improve internal employment practices in order to create affordable health
  care and wages that are comparable to other counties in the Central Valley.




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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




  Tulare Government: Perpetuating the Problem
  Initiative Four of the County’s Strategic Management Plan, states that it will:


                “Provide a qualified, productive, and
              competitively compensated workforce”                                                                                                             22



  However, the county has consistently failed to achieve this goal. As far
  back as 2001, a Grand Jury report showed rampant low morale among
  county employees and noted that a majority of workers were concerned
  with the low wages and benefits they receive as well as how it affects
  turnover and workload23.

  Inequitable Wages

  In a comparison of eight of Tulare County’s most common job
  classifications with nine neighboring agencies, County employees earned
  on average 13.3% less than their peers at other agencies. Employees in
  some positions earn up to 17.5% less than their peers. Figure 2 shows a
  comparison of a maximum salary of an Office Assistant III. In this
  classification, City of Visalia employees make more than $11,000 a year
  more than their counterparts who work for Tulare County24.

                                                     County Salary Comparison for Office Assistant III
              Maximum Annual Salary




                                      $45,000                                                                                                    $41,165
                                                                                                                                 $38,938 $39,972
                                      $40,000
                                                                            $33,240 $34,341 $34,968 $35,280
                                      $35,000             $32,076 $32,544
                                                $29,562
                                      $30,000
                                      $25,000

                                      $20,000
                                                                                                                                       it y
                                                                                                                   ity


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            Figure 2. Salary comparison for position of Office Assistant III. Source: Information provided by county/city personnel departments, April 22, 2008.



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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




  Tulare County employees continue to
  fall further behind as they have                                       While County workers
  received lower annual raises than                                        continue to receive
  employees at neighboring counties.
  These adjustments are less than what                                 minimal wage increases,
  comparable workers at Kings (12%),                                   the Board of Supervisors
  Fresno (11.75%), and Madera (7.5%)                                       implemented a new
  counties earned over the same                                          compensation plan for
  period25.
                                                                         Executive Management
  In contrast, the Board of Supervisors                                that allows for significant
  implemented a new compensation                                       increases in wages. The
  plan for executive management that                                   new system replaced the
  allows for significant increases in
  wages.     The new system replaced
                                                                      typical 5-step system with
  the typical 5-step system with broad                                     broad salary bands
  salary bands allowing wage increases                                  allowing wage increases
  of up to 10% each year, which is                                       of up to 10% each year.
  several times the amount that SEIU-
  represented county employees
  received in the previous year.
  In addition, the new system raises the maximum salary for management.
  The band for the County Administrative Officer26 is $120,000 to $180,000, a
  50% difference between the minimum and maximum salaries27. Prior to
  implementation, the CAO earned a flat rate of $160,650, and increases
  were limited 2% to 4% cost of living adjustments.

  Health Insurance Costs

  Most surrounding public employers recognize the benefits to employees
  and the community of creating family-supporting jobs that provide
  affordable health benefits. This is also true for many private sector
  employers, as a statewide survey of California employers showed that 94%
  of large firms (200 or more employees) contributed more than 50% of the
  total family health insurance premium for employees28.




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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




  Tulare County, on the other hand, contributes less than 30% toward family
  premiums for lower paid employees ranking behind both public and private
  sector employers. As a result, the employees’ share of health premiums is
  more than double those of neighboring counties29 (Figure 3).

  In 2008, Tulare County employees were required to pay up to $10,571 per
  year for the lowest cost family health coverage. This amount is thousands
  of dollar more than what employees pay in neighboring counties30


                                                                     Employee Health Contribution by County

                                      $12,000
                                                                 $10,571
          Annual Cost to Employee




                                      $10,000

                                        $8,000
                                                                                                                                                                               Employee
                                                           $5,404
                                        $6,000                                                                                                                                 Employee+1
                                                                                        $4,530
                                                                                                                                                           $4,167
                                                                                                                                     $3,588                                    Family
                                        $4,000                                 $3,010                     $2,492                                    $2,553
                                                                           $1,653                     $1,657
                                        $2,000                                                      $834                      $1,080
                                                        $534
                                                                                                                              $0                    $0
                                               $0
                                                            Tulare                 Kings                   Kern                Fresno                Madera

                                    Figure 3. Annual employee contribution to health premium. Source: County/agency employee benefits divisions, June 2008. Tulare figure uses cost
                                    to starting-salary Account Clerk.




                                             In 2008, Tulare County employees were
                                            required to pay up to $10,571 per year for
                                             the lowest cost family health coverage.
                                            This amount is thousands of dollars more
                                            than what employees pay in neighboring
                                                             counties.




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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




  Surprisingly, Tulare County’s health insurance premiums are similar to
  those in neighboring local governments, and even less than those in Kings
  County31. When employer contributions toward employee health benefits
  are compared across similar counties, it is clear that employees cannot
  afford coverage because Tulare refuses to provide affordable health
  benefits.    Although Tulare County contributes slightly more toward
  employee-only health coverage than Kings and Fresno Counties, Tulare
  contributes far less for Employee + 1 and Family health coverage plans
  (Table 1)32.
                Type of Coverage                          Tulare             Madera                Kings                Fresno               Kern
                Employee Only                             $4,466              $5,216                $3,885               $4,481              $3,334
                Employee + 1                              $4,466              $7,769                $7,075               $6,957              $6,628
                Employee + Family                         $4,466              $9,383               $10,646               $7,077              $9,968
               Table 1. Annual County contribution toward employee health benefits. Tulare calculation assumes starting salary for Account Clerk.



  As a result, the burden for paying for family health benefits has been shifted
  to Tulare County employees (Table 2)33. Furthermore, the formula used by
  Tulare County places a more significant burden on lower-wage employees,
  who are charged the most for health care.

                                                         Tulare            Kings              Kern              Fresno              Madera
                  % Employee Pays                        70.3%             29.9%              20.0%             33.6%               30.8%
                  % County Pays                          29.7%             70.1%              80.0%             66.4%               69.2%
                Table 2. Percent contribution toward family health coverage, employees vs. county. Tulare calculation assumes starting salary for
                Account Clerk.


  However, the employee share of health benefit premiums is not equal
  across the county. A 2000-2001 Tulare Grand Jury investigation exposed
  the fact that the County forced lower paid county employees to pay far
  more for the same health benefits than management employees such as
  the County Administrative Officer (CAO)34.

  Since then, the Board of Supervisors and County Executive Management
  have received regular increases in employer contributions for health care.
  The county formula that calculates the employer contribution for the Board
  of Supervisors and Executive Management amounts to 13% of salary. This
  is significantly higher than SEIU-represented bargaining units, and results
  in an annual contribution of at least $13,631 for a member of the Board of
  Supervisors35 and $22,704 for the CAO, Jean Rousseau36.


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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




   Health care contributions for management and employees were not always
   this disparate. In 1998, county employees and Executive Management
   received the same rate of contribution toward health benefits37.

   However, the Board of Supervisors has since approved regular changes to
   the health care contribution formula, vastly increasing the amount Board
   members and Executive Management receive38.

   As noted earlier, the 2000-2001 Grand Jury highlighted the discrepancy in
   the amount the County contributed to lower paid employees and higher
   paid employees such as the County Administrative Officer. The Grand Jury
   recommended the county equalize the rate of payment for employee health
   coverage. Instead, over that time period, the County’s share of health
   care premiums has become more divergent and now provides to higher
   paid employees, including the Board of Supervisors, more than three times
   what lower wage employees receive (Figure 4).

                                         Comparison of Employer Health Care Contributions for Tulare County Board of
                                                            Supervisors and County Employees


                                      $14,000
          Annual County Contributio




                                      $12,000

                                      $10,000
                                       $8,000                                                                                          Employees
                                       $6,000                                                                                          Board of Supervisors

                                       $4,000

                                       $2,000
                                          $0
                                             98

                                             99

                                             00

                                             01

                                             02

                                             03

                                             04

                                             05

                                             06

                                             07
                                           19

                                           19

                                           20

                                           20

                                           20

                                           20

                                           20

                                           20

                                           20

                                           20




     Figure 4 County contributions for the Tulare County Board of Supervisors and Tulare County employees Bargaining Units 1,3, 6, 7 from 1998-2007.




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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




   A Quality Workforce Threatened

   The growth in population has increased the demand for county services.
   Despite an increase in revenues of 35% and annual budget surpluses over
   the past several years, the County budgeted for few employees in 2007
   than in 200139.

   There is extensive evidence that jobs that do not provide competitive
   wages and affordable family health care coverage cause low morale and
   high turnover. These impacts undermine the ability of employees to
   provide high quality services that county residents rely on.

   County programs are plagued by high vacancy rates and high rates of
   turnover. In 2007, the annual turnover for county employees was
   approximately 15%, meaning that more than one out of every seven
   positions was vacant40.

   Documents provided by the County show a significant number of positions
   remained unfilled for a year or longer, including positions that provide
   critical services such as Child Support Officers and Mental Health Case
   Managers.

   The costs of high employee turnover, including reduced employee
   productivity and increased staff training time, are hard to quantify.
   However, published estimates suggest that the average per-worker
   turnover averages approximately 70% of person’s annual salary41.

   Tulare County’s employment practices are leaving its workforce further
   behind. While Executive Management and the Board of Supervisors
   continue to increase its own benefits, general workers are struggling to
   make ends meet.         This growing disparity between workers and
   management is not only affecting the quality of life of Tulare’s employees,
   but also the entire community.




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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




   Tulare Government Practices: The Impact on the
   Community
   Understanding the county government’s role in deepening the social and
   economic problems in the community is vital in order to develop workable
   solutions.

   A combination of decision making and misuse of county resources by the
   Board of Supervisors is escalating a myriad of issues that threaten the
   delivery of critical public services. Unless county leadership immediately
   addresses these issues, residents and businesses in Tulare County will
   soon feel the impact on many public services.

   Public Safety
   911 Emergency Services

   Tulare County Emergency Dispatchers working in the Sheriff’s Department
   serve as the answering point for all 911 calls for the police and fire
   departments. The program also provides night dispatch services for the cit-
   ies of Exeter, Farmersville, Woodlake, and Lindsay, and the County Roads
   and Animal Control departments. Added responsibilities from programs
   such as the Gang Task Force Hotline have also been assigned to the
   department.
   While responsibilities continue to grow, the
   department struggles to maintain adequate                                               911 Emergency
   staffing levels. Employees have reported that as                                         Services high
   a result of turnover and added responsibilities,                                       turnover rate and
   overtime levels have increased significantly. The
   high turnover rate and difficulty in recruiting
                                                                                             difficulty in
   qualified employees have resulted in a 15%                                                 recruiting
   vacancy rate for Emergency Dispatchers42. The                                               qualified
   strain on the department poses a potential public                                       employees have
   safety threat to residents.         Without the
   appropriate staffing levels to accommodate
                                                                                           resulted in 15%
   additional service areas and programs, residents                                        vacancy rate for
   could potentially experience longer wait times for                                        Emergency
   calls and response times for vital emergency                                              Dispatchers.
   services.
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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




   Probation Department

   The Tulare County Probation Department operates juvenile detention
   facilities, provides services for adult and juvenile offenders, and supports
   other law enforcement activities. The department suffers from chronic
   understaffing because of wages that are below those of neighboring
   jurisdictions.

   The impact to public safety from inadequate staffing was highlighted
   recently in the escape of two juvenile offenders accused of murder in
   December 2007. Immediately after the escapes, the County admitted that
   chronic staffing shortages forced the County to close sections of the
   Juvenile Justice Center43.



   Child Protection

   Tulare County provides services to
   protect and enhance the well-being of                                    An investigation by the
   children in the county.
                                                                               Tulare Grand Jury
   Employees provide a wide range of                                          confirmed that high
   social, health and protective services to                               turnover is contributing
   the County’s most vulnerable residents:                                    to delays in service
   children.       However, high turnover,                                   delivery. 30% of non-
   insufficient training for new staff, and an
   inability to recruit qualified staff threatens                           emergency cases were
   the department’s ability to fulfill this                                   in violation of state
   mission.                                                                standards, which are set
                                                                               to ensure counties
   The vacancy rate in the department is
   one of the highest in the county with                                     respond to reports of
   almost one in four positions unfilled44.                                 child abuse in a timely
   Staffing    shortages     have   forced                                          manner.
   employees to take on a higher number of
   caseloads, undermining their ability to
   provide the best service.

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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




   An investigation by the Tulare County Grand Jury confirmed that high
   turnover and lack of training could lead to serious harm to children in the
   county. The investigation found that staffing shortages contributed to
   delays in investigations of suspected cases of child abuse.

   These delays often result in the department’s violation of state standards
   set to ensure counties respond to reports of child abuse in a timely
   manner. The investigation also found that in some offices, 30% of
   non-emergency cases were in violation of state standards45. A recent
   study of the program also found that staff cited a lack of trained staff,
   lengthy hiring processes, and retention of staff as primary barriers to
   better practices46.

   Protecting Consumers
   The Agriculture Commissioner/Sealer of Weights and Measures

   The Agriculture Commissioner and Sealer of Weights and Measures
   provides quality control and related services that ensure the safety of
   agricultural and consumer products. The County’s low salaries for
   inspectors mean employees are constantly leaving to work in neighboring
   agencies and private sector employers that pay more competitive wages.
   This has resulted in high rates of employee turnover and a vacancy rate of
   11%47.

   The department struggles to recruit and retain the number of qualified
   inspectors that the County needs in order to carry out necessary quality
   control tests. Without the appropriate number of certified staff, consumer
   safety is potentially compromised.




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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




   Contributing to the Health Care Crisis

   The County’s decision to reduce health
   care services degrades the County’s                                       The 2007 closure of
   ability to provide the level and quality                                     health clinics in
   health services that resident’s depend                                   Porterville and Dinuba
   upon. The Board of Supervisor’s vote to                                 is expected to raise the
   close two of the six county-run health
   clinics in Porterville and Dinuba in 2007
                                                                            number of patients at
   significantly reduced community access                                     the Lindsay Health
   to affordable public health care. The                                       Center by at least
   two clinics served 8,144 medically                                              one-third.
   indigent patients in the Fiscal Year
   200648. Closure of these clinics was
   expected to raise the number of patients at the Lindsay clinic by at least
   one-third, increasing the burden on other community-based clinics.

   There is some evidence that publicly funded health programs suffer from
   what is termed “crowd-out”. Research indicates that “crowd out” occurs
   when an employer provided benefits are so expensive that parents are
   forced to decline employer provided health coverage for their children and
   instead enroll them in publicly funded programs49.

   Crowd-out may be a real concern in Tulare County where the high cost of
   County family health benefits has forced 98% of SEIU members to opt-out.
   Many employees have families and have no choice but to utilize publicly
   funded health insurance programs to gain coverage for their children. As a
   result, children of county employees may be “crowding out” children of
   other residents, especially children from families that truly have no other
   options for health care.

   The Healthy Kids program in Tulare County, which provides health care for
   children of families earning 250% to 300% above the federal poverty line,
   had a waiting list of over 1,150 children in 200750.




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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




   Mapping the Way Forward
   With the dramatic growth in population and businesses in Tulare County,
   the need for public services becomes more important than ever.
   Continued growth in the region will require changes to public policy and
   employment practices.

   As serious social and economic challenges continue to threaten the future
   prosperity of residents, county leadership will need to act quickly to
   implement policies to prevent a crisis that would result in a deterioration of
   services and the public workforce.

   Financial analysis demonstrates that Tulare County has the resources to
   improve public services and employment practices. However, decisions
   by county leadership have only exacerbated the problems.

   As the largest employer in the county, the Tulare County government is in
   a unique position to improve the overall economic and social wellbeing for
   its residents.

   Tulare County will need to follow in the footsteps of its counterparts in
   other regions of California by working with the community and employee
   associations to develop strategies that will provide and protect the quality
   of public services.

   Kern County- Investing in the Workforce

   The County of Kern struggled for years to retain and attract employees,
   which forced the county to rely on temporary workers to provide basic
   services. A combination of high health care costs and low salary
   increases resulted in the departure of many permanent employees. Kern
   continued to fall further behind, and the problems reached critical levels,
   with some departments reporting that one in five employees were
   temporary workers, including those working in public safety departments51.

   In an effort to improve employee retention and maintain these critical
   services, county management and leadership worked with employee
   associations to bring wages closer to market rates by providing across-the-
   board annual wage increases.
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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




   Furthermore, the county conducted an equity study on job classifications
   that were the furthest behind, resulting in the discovery that some jobs
   were up to 30% behind comparable counties. The county subsequently
   worked with employee associations to help eliminate this disparity and
   agreed to conduct annual equity studies.


   Santa Clara County- Investing Resources

   Santa Clara County received numerous complaints from its homecare
   workers that wages were not being paid in a timely manner. Occasionally,
   payments would be delayed for months. Failure to pay wages left
   homecare worker without any income, and threatened to leave elderly and
   disabled clients without the critical care they so depended upon.

   The Santa Clara County Grand Jury conducted an investigation and
   presented the findings to the Board of Supervisors. The Grand Jury found
   that the primary reason for the delayed payments was that the department
   did not have the resources to hire the staff necessary to ensure employees
   were paid on time. The Santa Clara County Board of Supervisors
   reviewed the findings of the report and held a public hearing on the topic.
   As a result, the Board voted to allocate funding so the department could
   hire the staff needed to solve to the problem and protect homecare
   services.




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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




   Working Together Leads to Quality Services

   Tulare County has begun to address the problems of recruiting and
   retaining employees in some areas. Recently, Tulare County employee
   associations have received recent salary and benefit contributions,
   bringing workers up to parity with other counties.

   •     In 2006, the Tulare County Deputy Sheriff’s Association (TCDSA) won
         a contract that included 21% increases over three years52
         (2007 to 2009).

   •     The Professional Law Enforcement Managers Assoc (PLEMA)
         negotiated a contract with Tulare County that awarded 18% increases
         over three years (2007 to 2009)53.

   •     The District Attorney Criminal Investigation Association (DACIATC)
         negotiated a contract with Tulare County that awarded a 7.5% increase
         during one year (2007)54.

   Employees of these associations receive larger health benefit contributions
   levels than SEIU-represented units55. Figure 5 shows the starting salaries
   that employees received in comparison to the allocation toward the
   average salary of SEIU-represented employees, and the base salary of
   members of the Board of Supervisors.

                                                  Comparison of County Health Contributions Toward Different Employee
                                                                             Associations
           Annual County Contribution




                                        $16,000
                                        $14,000
                                        $12,000
                                        $10,000
                                         $8,000
                                         $6,000
                                         $4,000
                                         $2,000
                                             $0
                                                      Board of      PLEMA       PLEMA               DACIATC   L521--Unit 4   L521--Unit
                                                     Supervisors   Captains   Lieutenants                                      1367

         Figure 5 Employee Association Comparison of Health Benefit Contributions from Employers.



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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




   The County increased health care contributions for some employees as
   well. For example, TCDSA bargained significantly higher benefits with
   tiered annual contributions based on the plan that the employee chooses56:

   • Employee only - $5,976.88
   • Employee + 1 - $8,099.26
   • Employee + Family - $11,043.50

   Community Oversight of Tobacco Settlement Funds

   The financial health of Tulare County empowers its leaders to create
   significant long-term improvements that will resolve a myriad of problems.
   The County’s decision to establish the Millennium Fund without community
   input resulted in public backlash.

   The County receives over $4 million dollars a year in tobacco tax
   settlement dollars. However, the Board of Supervisors legally restricts the
   use of this money for capital projects instead of investing in health
   programs. In order to ensure that the county is using tobacco tax settle-
   ment revenue for the greatest needs of its residents, the Board of
   Supervisors should follow the lead of other counties and implement true
   community oversight over the use of tobacco tax funds.

   The Santa Barbara County Board of Supervisors voted unanimously back
   in 1999 that the Tobacco Settlement funds would be used to fund County
   health-related programs and services. The Board also created the
   Tobacco Settlement Advisory Committee (TSAC) to be comprised of
   community members to present recommendations for funding57.

   Orange County drafted Measure H, which would ensured tobacco
   settlement funding was used for health related programs, on a ballot for
   vote. The Board then established the Health Care Tobacco Settlement
   Revenue Advisory Group to provide community recommendations on the
   distribution of Tobacco Settlement Revenue to the Health Care Agency in
   a manner that conforms to the requirements of Measure H58.




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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




   Protecting Tulare’s Future

   Investing in county resources will not only create more efficient services,
   but will also provide affordable health care, increase consumer spending
   and alleviate the strain on public health care programs. As a result, the
   looming crises of poverty and poor health conditions will also subside.

   This report has outlined the immediate and future challenges in Tulare, in
   addition to analyzing Tulare County’s fiscal ability to create positive
   changes in its employment practices and service delivery.
   Accommodating significant population and economic growth hinges on
   County leadership’s willingness to plan for the future.

   Accountability-Working with the Community

   County leadership has repeatedly dismissed and ignored audits of county
   services by the Tulare Grand Jury, which has identified numerous
   problems in multiple agencies. The Board should be held accountable for
   the operations of the County and the quality of public services provided by
   the county. The consequences of Tulare County’s failure in these areas
   are resulting in the decline of quality services, including those that protect
   pubic safety, families and children.

   Prioritize Spending

   Tulare County’s finances have improved dramatically over the past 3
   years, receiving regular annual increases in revenue and increases in fund
   balances, which includes funds budgeted for job positions that were never
   filled.

   In addition, Tulare County is receiving over $4 million in tobacco tax
   revenue annually which is diverted to the Millennium Fund, with revenues
   totaling $37.4 million as of 2008 and an estimated total of $60 million by
   2013.




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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




   Cooperation and Collaboration- Investing in the Public
   Workforce and Services

   Tulare County should reprioritize spending of county resources to increase
   the funding available for public services. This report recommends that
   Tulare County:

   •     Re-open discussions about the uses for the Millennium Fund.
         Suggestions and recommendations from citizen groups should be fully
         considered with a focus on using the funds for health care. By directing
         a portion of the money toward health insurance premiums for its own
         employees, county worker benefits would be closer or equal to
         management benefits. County workers would subsequently have
         affordable health care and increased purchasing power, thus increasing
         the economic well-being of Tulare. By directing resources towards
         health care programs and benefits, the County could take full
         advantage of thousands of dollars of matching funds for staff whose
         wages and benefits are fully or partially reimbursed with federal and
         state funds. Furthermore, county workers eligible for government
         sponsored Medi-Cal or Healthy Families would no longer need to
         depend on these tax payer resources, removing a shameful practice for
         the largest employer in the county to make its own workers depend on
         publicly funded programs for their health care.

   •     Conduct a review and audit of Tulare County’s specialized funds. If an
         audit were to discover any surpluses as suggested by this report, the
         County should move the resources into the General Fund to provide
         necessary services to the community. An audit should also be con-
         ducted on the Redevelopment Agency funds to confirm if loans to this
         fund have been repaid. In addition, the Worker’s Compensation Fund
         should be reviewed to ensure that ongoing payments are sufficient and
         whether the fund balance is large.




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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




   •     Take the appropriate steps to begin resolving high turnover and
         vacancy rates in numerous county departments, which are causing
         unreliable and inefficient service delivery to the community as well as
         low employee morale. The County should perform a salary and
         benefits audit for job classifications that compare Tulare with nearby
         public agencies to ensure that the county is doing its best to recruit and
         retain the highest quality staff. Once the audit is completed, the County
         should meet with the affected employee groups to develop an equitable
         solution in implementing necessary improvements.

   •     Hire a reputable Public Government Audit firm to review accounting
         practices and fiscal safeguards and request recommendations for
         improvements in accounting, financing and purchasing. The audit
         should also include ways to maximize interest received, maximize
         state and federal matching funds, and minimize interest payments.




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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community


   References
   1. Department of Finance (2007). Population Projections for California and Its
       Counties 2000-2050, by Age, Gender and Race/Ethnicity. Sacramento, CA:
       State of California.
   2. US Dept of Agriculture, Economic Research Service (2008) California State
       Fact Sheet. Retrieved Aug. 27, 2008, from http://www.ers.usda.gov/
       statefacts; California Farm Bureau Federation (2008). Tulare County: Top five
       crops by value, 2007. Retrieved Aug. 27, 2008, from http://www.cfbf.com/
       counties/?id=54.
   3. US Census Bureau (2008). Decennial Census, Summary File 3 sample data,
       provided by DataPlace (http://www.dataplace.org). Retrieved Aug. 27, 2008.
   4. U.S. Census Bureau. (2000). Summary File 1 (SF 1) and Summary File 3 (SF
       3). Center for Health Policy Research (2005). California Health Interview
       Survey. Los Angeles: University of California.
   5. Center for Health Policy Research (2005). California Health Interview Survey.
       Los Angeles: University of California.
   6. Meeks, H.S. (2008, April 10). Health focus shifts to prevention: Research indi-
       cates most deaths in Tulare County are preventable. Visalia Times-Delta.
   7. Staff (2008, April 18). Supervisors vote to close health clinics. Visalia Times-
       Delta.
   8. Diringer, J., Curtis, K. A., Paul, C. M., Deveau, D. R. (2004). Health in the
       Heartland: The Crisis Continues. Fresno, CA: California State University,
       Fresno.
   9. Bengiamin, M., Capitman, J.A., and Chang, X. (2008). Healthy people 2010:
       A 2007 profile of health status in the San Joaquin Valley. Fresno, CA: Califor-
       nia State University, Fresno.
   10. Bengiamin, M., Capitman, J.A., and Chang, X. (2008). Healthy people 2010:
       A 2007 profile of health status in the San Joaquin Valley. Fresno, CA: Califor-
       nia State University, Fresno.
   11. Chernabaeff, J. (2006, August 15). Water woes plague rural areas. Visalia
       Times-Delta.
   12. Tulare County Economic Development Corporation (2007). Tulare County
       Major Employers List—2007. Retrieved Aug. 27, 2008, from http://
       www.sequoiavalley.com/default.asp?contentID=581.
   13. Tulare County Comprehensive Annual Financial Reports (CAFR), FY 2004-
       2005, 2005-2006, and 2006-2007.
   14. Tulare County Comprehensive Annual Financial Reports (CAFR), FY 2004-
       2005, 2005-2006, and 2006-2007.
   15. Mialocq, R. (2008). Financial assessment of Tulare County. San Francisco:
       Harvey M. Rose Associates, LLC.
   16. Fontana, C & Ginis, K. (2008, April 20) Spending more, getting less, Fresno
       Bee.


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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community


   17. Legislative Analyst's Office (1999). What will it mean for California: The To-
       bacco Settlement. Sacramento: State of California. Retrieved Aug. 27, 2008,
       from http://www.lao.ca.gov/1999/011499_tobacco_settlement.html.
   18. Legislative Analyst's Office (1999). What will it mean for California: The To-
       bacco Settlement. Sacramento: State of California. Retrieved Aug. 27, 2008,
       from http://www.lao.ca.gov/1999/011499_tobacco_settlement.html.
   19. Tulare County (2006). Agenda of the Tulare County Public Financing Author-
       ity. December 5, 2006.
   20. Griswold, L. (2000, August 16). Tulare County rejects push to use tobacco
       settlement funds for health care. Fresno Bee.
   21. Fontana, C & Ginis, K. (2008, April 20) Spending more, getting less, Fresno
       Bee.
   22. Lacayo, E. (2008, May 4).Visions clash in Tulare County race. Fresno Bee.
   23. Tulare County (2006). Strategic Business Plan, 2006-2011. Retrieved Aug.
       27, 2008 from http://www.co.tulare.ca.us/civica/filebank/blobdload.asp?
       BlobID=4052.
   24. Tulare County Grand Jury Report, 2000-2001.
   25. Information provided by county/city personnel departments, April 22, 2008.
   26. County employee organization MOUs, 2005-2007
   27. Tulare County (2007). Board of Supervisors Agenda Item. October 30, 2007.
   28. Tulare County (2007). County of Tulare Classification Listing. January 8,
       2007.
   29. California HealthCare Foundation (2007). California Employer Health Benefits
       Survey. Oakland, CA.
   30. Information provided by county personnel/employee benefit departments,
       June 10, 2008.
   31. Calculated using county employee salaries from Tulare County Dept. of HR
       website and employee benefit formulas noted in employee organization
       MOUs.
   32. Information provided by county personnel/employee benefit departments,
       June 10, 2008.
   33. Information provided by county personnel/employee benefit departments,
       June 10, 2008.
   34. Information provided by county personnel/employee benefit departments,
       June 10, 2008.
   35. Tulare County Grand Jury Report, 2001-2002.
   36. Calculated using Board of Supervisor base salary from County of Tulare
       Classification Listing (dated 3/4/08) and benefit formula from document titled
       “Employee Benefit Amount History by Unit” provided by the Tulare County
       Dept of HR on Dec. 11, 2007
   37. Calculated using CAO base salary provided by Tulare County Dept of HR
       (phone contact with Eric Martin, 6/13/08) and benefit formula from document
       titled “Employee Benefit Amount History by Unit” provided by the Tulare
       County Dept of HR on Dec. 11, 2007.
                                                                                                                            30
A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community


   38. “Employee Benefit Amount History by Unit” provided by the Tulare County
       Dept. of HR on Dec. 11, 2007.
   39. Tulare County Comprehensive Annual Financial Report, FY 2006-2007
   40. Calculated using information provided by the Tulare County Dept. of HR on
       Dec. 11, 2007 and April 15, 2008.
   41. American Public Human Services Association.
   42. Vacancy information provided by the Tulare County Dept. of HR on July 28,
       2008. Position Allocation available in 2007-2008 Adopted Budget.
   43. Bragg, T (2007, December 15). Probation staff shortage admitted: Teens' es-
       cape shines light on Tulare County crunch. Fresno Bee.
   44. Vacancy information provided by the Tulare County Dept. of HR on July 28,
       2008. Position Allocation available in 2007-2008 Adopted Budget.
   45. Tulare County Grand Jury Report, 1999-2000.
   46. Robles, J. (2005). California – Child Welfare Outcomes and Accountability
       System Peer Quality Case Review (PQCR). Tulare County Health & Human
       Service Agency, Child Welfare Services Division.
   47. Vacancy information provided by the Tulare County Dept. of HR on July 28,
       2008. Position Allocation available in 2007-2008 Adopted Budget.
   48. Chernabaeff, J. (2007, March 23). County may close two clinics. Visalia
       Times-Delta.
   49. Hughes, D., Angeles, J., & E. Stilling (2002). Crowd-Out in the Healthy Fami-
       lies Program: Does it Exist? Institute for Health Policy Studies. San Fran-
       cisco: University of California.
   50. Institute for Health Policy Solutions, California (2007). Overview of Local Chil-
       dren’s Coverage Expansions. Retrieved Aug. 27, 2008, from http://www.ihps-
       ca.org/localcovsol/_pdfs/WebsiteTableDocument_040607.pdf
   51. SEIU analysis of Kern County staffing patterns, 2007.
   52. Tulare County MOU with the Tulare County Deputy Sheriff’s Association,
       2006-2010.
   53. Tulare County MOU with the Professional Law Enforcement Managers Asso-
       ciation, 2007-2009.
   54. Tulare County MOU with the District Attorney Criminal Investigators Associa-
       tion, 2007-2008.
   55. Information provided by the Tulare County Dept. of HR on Dec. 11, 2007.
   56. “Employee Benefit Amount History by Unit” provided by the Tulare County
       Dept. of HR on Dec. 11, 2007.
   57. Santa Barbara County Public Health Department (2008). Tobacco Settlement
       Advisory Committee. Retrieved Aug. 27, 2008 from http://www.sbcphd.org/
       tsac/default.html
   58. Felland, L.E., Kinner, J.K. and J.F. Hoadley (2003). The health care safety
       net: Money matters but savvy leadership counts. The Center for Studying
       Health System Change. Issue Brief No. 66. Retrieved Aug. 27, 2008 from
       http://www.hschange.org/content/.

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A Crisis in Tulare: The Impact of Tulare County Policies and the Threat to Vital Public Services, Jobs, and the Community




    SEIU Local 521
    2302 Zanker Road
    San Jose, CA 95131
    (408) 678-330
    www.seiu521.org


                                                                                                                            32

								
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