A white building with trees in front of it.

Reforming Rhode Island government’s human services safety net – Richard Asinof

by Richard Asinof, ConvergenceRI, contributing writer

The last televised debate between the Democratic candidates running for Governor in 2022 will occur on Tuesday, Sept. 6, a week before the primary election. But the odds are pretty good that there will be no questions – or answers – about the release of the report by the Senate Commission and its far-reaching recommendations about how to reshape the R.I. Executive Office of Health and Human Services.

Of course, the release of the report was apparently timed to coincide with the Friday afternoon before the long Labor Day weekend, the equivalent of 72 hours worth of dead air on the radio, so the chances of any reporters taking a deep dive into the recommendations in advance of the debate are miniscule. ConvergenceRI, however, was paying attention.

The recommendations reflect the best attempt by Rhode Island’s “professional-managerial class” [an apt term coined by the late Barbara Ehrenreich in her 1970 book, The American Health Empire: Power, Profits and Politics] to reform the beast that is the human safety net agency.

For sure, questions about the R.I. Medicaid program, which consumes nearly one-third of the state’s annual budget, will probably not be on anyone’s Debate Bingo card. Nor will any of the candidates – or reporters asking the questions – be able to say, if asked, how many Rhode Islanders currently are receiving their health care coverage through Medicaid. Suffice it to say that there are roughly 350,000 Rhode Island residents receiving Medicaid – more than one third of the state’s population.

Translated, the state of Rhode Island, in its perpetual search of a path to economic prosperity, has created what seems to be a permanent underclass, constantly being, once again, in the words of Ehrenreich, in a 2011 interview, condemned to “extreme insecurity.”

“Jobs that don’t pay enough to live on do not cure poverty,” Ehrenreich said. “They condemn you, in fact, to live a life of low-wage labor and extreme insecurity.”

But, make no mistake about Medicaid: it is a big, big, big business. In the cowboy vernacular of epic Western movies, “Thar’s gold in them there Medicaid bills.” The state is currently engaged in the re-procurement process for the Managed Care Organizations that provide roughly 90 percent of the care for those enrolled in Medicaid in Rhode Island, a contract estimated to be worth some $7 billion over the next five years, beginning on July 1, 2023.

Translated, the next Governor will be in charge of a state budget where one-third of all the tax dollars go to pay for Medicaid services – but much of that money will end up in the pockets of insurance providers. Without an audit of the current MCOs commissioned by the General Assembly, we will become spectators of watching the money flow, without any accountability.

Just before the start of the inaugural meeting on Wednesday, Oct. 27 of the Senate Legislative Commission to review and make recommendations regarding the efficient and effective administration of health and human services programs in the state of Rhode Island. From left: Michael DiBiase [seated], Marie Ganim, standing next to Sen. Lou Di Palma, Sen. Josh Miller [seated], Tina Spears, standing, talking to Elena Nicolella, seated.

What the Commission report said
The entire report is 198 pages long, creating a comprehensive record of the testimony heard, including the hearings broadcast over Capitol TV. The history and the context is important, because it revealed exactly how broken the system is, and the incredible disconnects in the difficulties of gaining access to services. [ConvergenceRI reported extensively on the hearings, so there are links below to the numerous stories published in the last year.]

So much of the current crises in our everyday working world – the crisis in the health care workforce, the breakdown of behavioral health and mental health services, the cascading effects of unmet needs for children with mental health conditions, the state’s inability to provide access to services for the state’s “unhoused” population, the escalation of substance use disorders and addiction, the potential insolvency of the state’s hospital system and the unsustainable enterprise of the private hospital health care delivery system, and the enduring difficulties of the state’s nursing home industry – are linked to low Medicaid rates.

Still, in the interest in providing a complete and accurate record of the Commission’s recommendations, here they are:

• Recommendation One: Create a Medicaid Department within EOHHS and elevate the role of Medicaid Director, requiring Advice and Consent by the Senate.

This would put the Medicaid Director on the same level as the other sub-agency directors within EOHHS. Currently, EOHHS and Medicaid are intertwined, which complicates Medicaid’s work with other departments.

A dedicated Medicaid Department would be less influenced by competing priorities within the executive office. It would allow EOHHS to focus more attention and resources on streamlining centralized services, as well as carrying out a coordination and oversight role.

Additionally, Medicaid’s large budget, which is nearly one-third of the state’s budget, warrants holding the Medicaid Director directly accountable to the Governor and the General Assembly.

The commission heard multiple experts discuss the idea of creating a Medicaid Department – the topic was thoroughly debated and potential opportunities and challenges were explored. During the Feb. 2 meeting of the commission, Gretchen Hammer of the Public Leadership Group and former Medicaid Director in Colorado, spoke to the commission about trends in how health and human services agencies are structured nationwide. Ms. Hammer reported that typically, states with smaller populations have highly integrated health and human services functions – likely due to the size of state government, and because the population is receiving services from multiple programs at the same time.

She further reported that 74 percent of Medicaid agencies in the United States are subdivisions within a larger HHS structure. However, within those larger HHS structures, Medicaid most often operates as an independent division with directors who are peers with directors in other divisions [e.g. the director of the department of human services].

In contrast, currently in Rhode Island, Medicaid is embedded within the Executive Office of Health and Human Services “as an infrastructure program that is supporting everything,” which differs from how other states tend to operate. Ms. Hammer stated: “I do think that there is some nuance in the things that you all are considering in that structure … there is a strong precedence for an integrated health and human services model, but that there may be opportunities for you to consider an independent or more defined department or division for your Medicaid program to clarify.”

Furthermore, during the same meeting, Linda Katz, Co-Founder and Policy Director of the Economic Progress Institute and a longtime advocate in Rhode Island, recommended making the Medicaid Director an independent position who would be responsible for all the duties related to Medicaid set forth in Rhode Island General Law § 42-7.2-5.

Ultimately, based on expert testimony and much discussion, the majority of commission members recommend creating a separate Medicaid Department operating under EOHHS as the other sub-agencies currently do.

This recommendation would require legislation to create a new department. The legislation would charge the Medicaid Director with ensuring that the use of Medicaid funds meets federal rules. The Medicaid Department would provide expertise and policy support to the other sub-agencies to maximize federal Rhode Island Medicaid dollars for the Medicaid-eligible populations they serve.

Legislation would shift Medicaid resources, staff, and authority from the executive office to the new department. The legislation would also outline an organizational structure and other essential guardrails to ensure clear lines of communication and coordination between Medicaid and the other EOHHS agencies. This would include Medicaid staff who would act as liaisons to the other sub-agencies and support those agencies’ initiatives to improve services for their constituents.

• Recommendation Two: Remove Hospitals from the Department of Behavioral Health, Developmental Disabilities and Hospitals and create a Department of Hospitals.

This would allow for more targeted expertise in the leadership of the new Department of Hospitals – hospital management is a distinct skill set from other types of departmental management and should be treated as such.

In recent years, Eleanor Slater Hospital has had a number of federal compliance and licensing issues that have negatively affected the entire department. The commission believes that a Department of Hospitals would benefit from experienced leadership that can focus solely on hospital management.

The Department of Hospitals would be a department within EOHHS, like DOH and DHS, and would include Eleanor Slater Hospital [on two campuses], the RI Veterans Home, and the new RI Psychiatric Hospital that was established in the fiscal year 2023 budget.

The commission recommends that private-sector salaries be evaluated and used as a reference point when setting the salaries for leadership roles within the Department of Hospitals so that the state can recruit and retain experienced professionals to run the new department.

Creating a new Department of Hospitals would require legislation to shift BHDDH hospital programs and the RI Veterans Home to the new department.

The commission also recommends that EOHHS explore whether it would be beneficial to make the Department of Hospitals a quasi-public agency. Status as a quasi-public agency would allow the department to respond to issues and opportunities faster and more efficiently than a comparable state agency while also maintaining a degree of oversight and accountability to the state.

In a memo sent from EOHHS to the commission on August 2, 2022, EOHHS expresses agreement with the commission’s recommendation to remove hospitals from BHDDH and states, “We do believe the hospitals may benefit as a quasi-public agency.”

Additionally, removing hospitals from the Department of Behavioral Health, Developmental Disabilities and Hospitals would enable the new BHDD to focus more closely on its remaining two divisions: behavioral health and developmental disabilities.

• Recommendation Three: Add children’s behavioral health [BH] and children’s developmental disabilities [DD] to the charge of BHDD within a timeframe as recommended by EOHHS and other stakeholders.

The commission recommends that this transfer occur contingent upon the recommendation to remove hospitals from BHDDH.

As stated above, removing hospitals from BHDDH would allow the department to focus on BH and DD, therefore creating bandwidth to take on children’s BH and DD. Legislation would be required to shift the responsibility of overseeing the state’s BH and DD systems of care from DCYF to BHDDH.

Adding children’s BH and DD programs to BHDD would promote an integrated continuum of care and would improve the youth to adult services transition process.

Currently, the Department of Children Youth and Families [DCYF] is charged with overseeing the statewide system of care for children and youth requiring behavioral health services, including those children who are involved with the department due to abuse or neglect.

According to EOHHS, “In calendar year 2021, there were 110,125 children with any Medicaid claim. Of those, 29,950 [27 percent] had at least one Medicaid claim for a behavioral health service. And, of the 110,215 children, 15,533 [14 percent] are involved in DCYF. The number of children in calendar year 2021 who are involved with DCYF and have a behavioral health Medicaid claim is 6,853 [6 percent].”

Therefore, the proportion of non-DCYF-involved children on Medicaid with a behavioral health claim is higher than the proportion of DCYF-involved children with a behavioral health claim. Additionally, it was anecdotally reported to the commission that families who are not involved with DCYF due to abuse or neglect are hesitant to engage with the department for purposes strictly related to BH or DD, which hinders access to such services.

For these reasons, having both youth and adult services fall under one department would make services accessible without reference to whether the child’s guardian is a family or the state, thus increasing access to services.

A memo from the Rhode Island Coalition for Children and Families to the commission aptly explains: “Children’s behavioral health policy, programming, data collection, and resourcing currently are situated in multiple governmental departments and private sector organizations and insurers. DCYF has statutory responsibility for children with serious emotional disturbance, BHDDH has responsibility for youth substance use, RIDOH has oversight of family visiting programs, RIDE has oversight of school programming, DHS has oversight of early care and education, EOHHS/Medicaid and OHIC has program, policy, and insurance oversight responsibility, and community-based organizations and hospitals are the primary providers of services, and youth and families are the beneficiaries of service. These groups are all key stakeholders in the children’s behavioral health system.”

The commission recognizes that the timing of this recommendation is crucial – moving children’s BH and DD from DCYF to BHDD is a large undertaking that will require strong leadership and inter-agency cooperation. Executing this recommendation at an inappropriate time could impede service delivery, which is counter to the commission’s goals.

Therefore, the commission further recommends that EOHHS convene all aforementioned stakeholders to review and recommend a transition plan for moving children’s BH and DD to BHDD. The stakeholders’ plan should include an appropriate and justified timeline for this transition and recommend a leadership and administrative structure within BHDD to oversee a comprehensive children’s behavioral health system. The plan should establish a process for design, implementation, and resourcing of such a structure and system.

The commission recommends that this stakeholder group provide a report to the General Assembly by Jan. 1, 2023.

• Recommendation Four: Strengthen accountability by giving the EOHHS Secretary authority to make recommendations to the Governor regarding appointment and removal of the agency directors.

The Governor would be required to give due consideration to the recommendations of the EOHHS Secretary regarding the appointment and removal of directors of the agencies that report to EOHHS. This would give the Secretary an official role in the selection process of those directors who will be held accountable to the Secretary, to help form an effective and efficient team.

The authority regarding removal recommendations would give the Secretary a role in addressing accountability issues to ensure success of the EOHHS team.

The Secretary of Massachusetts’s Executive Office of Health and Human Services, Marylou Sudders, presented to the commission during the February 16th meeting. Secretary Sudders made it clear that her ability to recommend, evaluate, and remove agency directors is an important tool that allows her to hold directors accountable, and strengthens her authority and effectiveness as a leader.

The commission gave strong consideration to Secretary Sudders’ testimony and the Massachusetts model of agency appointments and accountability, surfacing both the strengths of such a reporting structure as well as the constitutional and practical questions if such a model were to be recommended for Rhode Island.

Ultimately, Secretary Sudders’ testimony and insight informed the commission’s recommendation to give the Secretary the authority to make recommendations to the Governor regarding the appointment and removal of the sub-agency directors. Legislation would be required to accomplish this recommendation.

• Recommendation Five: Create a stakeholder group to ensure appropriate input for the rate review process that was included in the 2023 budget to hold the Office of the Health Insurance Commissioner [OHIC] accountable through public meetings, ensuring that the process is transparent.

The fiscal year 2023 budget allocates $1.5 million to OHIC to “conduct a comprehensive analysis of all state licensed and contracted social and human service providers, to include review of rates, eligibility, utilization, and accountability standards pursuant to Rhode Island General Law, Section 42-14.5-3(t).”

The new law requires OHIC to conduct public meetings to allow stakeholders the opportunity to ask questions and provide comment. The new law also requires consultation with EOHHS. Though the law requires that public meetings be held, the commission recommends that a formal stakeholder group also be created.

This recommendation could be accomplished through executive action; legislation would not be required.

Additionally, commission members expressed a need for tracking community access to social and human services programs provided by the state and by state-contracted providers. The new law will require “an assessment and reporting on access to social and human service programs, to include any wait lists and length of time on wait lists, in each service category.”

The commission supports this provision, which can be used to hold the Secretary accountable for improving access to services in the community.

• Recommendation Six: Create a Health and Human Services Cabinet, which the Secretary would be held accountable for convening, in order to achieve certain outcomes that would be reported to the legislature on a regular basis.

The cabinet would be required to regularly hold public meetings, which would increase transparency and improve accountability between member-agencies and to the public. The commission recognizes that to be successful, the cabinet needs to be appropriately resourced and staffed.

This cabinet would be a similar model to the Children’s Cabinet and would be established in statute.

The Health and Human Services Cabinet would work to strengthen cross-agency alignment, effectively use data, and ultimately coordinate policies and programs that advance equity, eliminate disparities, and improve population level outcomes.

The commission recommends that the cabinet include all agencies within EOHHS [BHDDH, DCYF, DHS, and DOH], the new agencies proposed to be created in this document, OHIC, HealthSource Rhode Island, the Secretary of Housing, the Department of Education, the Department of Corrections, Department of Labor and Training, the Department of Administration, and community provider agencies.

The recommended composition represents agencies that work directly in health and human services along with agencies that work in areas related to the social determinants of health, enabling the cabinet to work towards administering health and human services in a holistic manner.

Additionally, the commission recommends that the Health and Human Services Cabinet have a formal relationship with a higher education partner that would provide staff support and research capabilities to the cabinet.

Recommendation Seven: Increase the salary of the Secretary of EOHHS, and the salaries of the directors of agencies that report to EOHHS, in order to support recruitment and retention.

In recent history, it has been challenging to recruit a secretary and directors – as is evident by the current leadership vacancies within EOHHS and its sub-agencies. It is extremely important for agencies to have strong leadership in place to promote stability in the HHS agencies.

The Secretary oversees the largest state budget, and programs under EOHHS affect a large portion of the Rhode Island population. The commission recommends that a salary increase be based on comparable leadership positions within state government, including the Secretary of Commerce and the Health Insurance Commissioner.

The new salary should also be competitive with comparable roles in the region. A salary increase would need to be included in the state budget.

The fiscal year 2023 budget allows the Department of Administration to propose salary increases for agency directors to the General Assembly by October 30, 2022. The commission recommends significant increases to the salaries of the Secretary of EOHHS, in addition to increases for the directors of the agencies within in EOHHS.

The work of these agencies is complex and should be compensated accordingly to attract skilled candidates. Together with sufficient provider rates, appropriate compensation structures within EOHHS will support leadership continuity, talent acquisition, and overall workforce stabilization across the health and human services ecosystem in Rhode Island.

• Recommendation Eight: Include the Department of Children, Youth and Families in the biannual Caseload Estimating Conference [CEC].

The CEC is an open public meeting held each May and November to forecast caseloads to provide for a more stable and accurate method of financial planning and budgeting.

The Governor’s budget is required to include the estimates determined by the CEC in the executive budget, and the General Assembly must make appropriations in accordance with the estimates.

Currently, certain programs within BHDDH, DHS, and EOHHS are included in the CEC. The commission recommends that DCYF be included in the CEC to improve the department’s financial planning and budgeting process.

Legislation would be required to include DCYF in the CEC.

The commission further recommends that caseload estimates inform staffing levels within EOHHS, its sub-agencies, and within the community agencies who provide state-contracted health and human services to Rhode Islanders.

The commission specifically acknowledges a need for more attorneys within EOHHS. An appropriate number of attorneys assigned to EOHHS and each sub-agency should be determined based on scope of work, including caseloads and the specific fluctuating legal needs of a department at any given time [e.g. managing federal court oversight of a department. The commission heard that it is beneficial for EOHHS to employ a “law firm” model and deploy attorneys to each department based on the current legal needs of a department at any given time.

The commission also heard that certain agencies have lost attorneys to other agencies based on higher pay and less demanding workloads. The commission recommends that EOHHS appropriately staff each agency to meet legal needs, and that EOHHS conduct a wage analysis to ensure that the compensation structure does not lead to agencies competing among each other for attorneys.

What the news reporters didn’t report
The recommendations by the Senate Commission represent, in ConvergenceRI’s opinion, a courageous effort to reform the shortcomings of the R.I. Executive Office of Health and Human Services, achieving a consensus approach on how to move forward.

The problem with the recommendation is “self-evident,” which is the truth about the legislative process, often referred to as “sausage making.” It depends upon the ability of the legislative leadership to exercise the same kind of courage and move beyond their desire to preserve the status quo – and their indebtedness to corporate lobbyists.

The big question is: Will the next Governor be willing to push the envelope when it comes to these recommendations?


Richard Asinof

Richard Asinof is the founder and editor of ConvergenceRI, an online subscription newsletter offering news and analysis at the convergence of health, science, technology and innovation in Rhode Island.

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