The high profile, heart wrenching deaths of Iowa children has launched legislative investigations and new leadership at the Department of Human Services. We dive deeper into the controversial issues on this edition of Iowa Press.

Funding for Iowa Press was provided by Friends, the Iowa Public Television Foundation. The Associated General Contractors of Iowa, the public's partner in building Iowa's highway, bridge and municipal utility infrastructure. I'm a dad. I am a mom. I'm a kid. I'm a kid at heart. I'm a banker. I'm an Iowa banker. No matter who you are there is an Iowa banker who is ready to help you get where you want to go. Iowa Bankers, allowing you to discover the genuine difference of Iowa banks.

(music) 

For decades, Iowa Press has brought you politicians and newsmakers from across Iowa and beyond. Now celebrating more than 40 years of broadcast excellence on statewide Iowa Public Television, this is the Friday, September 15 edition of Iowa Press. Here is David Yepsen.

Yepsen: The past year has brought some disturbing headlines to Iowans, multiple deaths of children under foster or adopted care. Policymakers in Des Moines are reassessing oversight procedures and developing new regulations. This summer, longtime child rights advocate Jerry Foxhoven was appointed to head the Iowa Department of Human Services which provides everything from food assistance to Medicaid and mental health programs for Iowans. And Senator Matt McCoy has been critical of the state's oversight efforts in these matters. Both men join us here at the Iowa Press table. Welcome to you both.

Thanks.

Thank you.

Yepsen: Across the table, Barbara Rodriguez covers the Iowa Statehouse for the Associated Press and Kay Henderson is News Director at Radio Iowa.

Henderson: Mr. Foxhoven, there have been two high profile criminal cases involving foster care children, adopted and being home schooled. Other than the independent review that is underway in your agency that happened before you started, what have you authorized in terms of changes in the foster care system and the child welfare system?

Foxhoven: A number of changes have occurred already that are kind of driven by us taking a look at that and there's more to come. The first is that we have already determined that, or at least my position from the very beginning was, we need to start taking a look at people who have received an adoption subsidy, both of those cases they did, and we need to make sure that the parents that adopt these kids have some continued responsibility. And so one of those is to make sure that anybody who receives an adoption subsidy takes the child to the doctor at least once a year. We're looking at other possibilities. But at least that much on a minimum. Secondly, what we've done was to try to change how we took reports, child abuse reports. In the past when a child report would come in, if another one came in we treated it as an addendum to the first report and the same person investigating would investigate. There's not a problem with the same person investigating, it's just that if two or three or four different reports come in on a child kind of in the same time and there just is an addendum, when a worker looks back at that incident they see one child abuse report rather than four or five. And so of course it doesn't create the red flag that it should have done. That has already been changed.

Rodriguez: Jerry, Kay referenced that consulting group that is coming in and making some recommendations. There's the real possibility that they may recommend hiring more staff and spending more money. Will you do that if they recommend so?

Foxhoven: Well, Senator McCoy is in the legislature, I'm not, so the legislature sets the budget. I'm committed to take a look at whatever that group recommends and see what we can do to fulfill -- I mean, we hired them for a reason and that is to help us identify what changes need to be made and to try to fulfill those.

Yepsen: Senator McCoy, what is your reaction to all that?

McCoy: Well, first of all, I think that Jerry is bringing the right emphasis as he comes into the department and tries to deal with these challenges. I do think that the consulting group that was hired should have more transparency. I'm concerned about making sure that they're really getting to the issues that I think are systematic failures within the system and I think they need to involve legislators in that process. Secondly, I think that whatever changes they make and whatever recommendations that they come forward with, I think that additional resources, staffing and funding, is going to be key to allowing Jerry to really be successful in this new role that he has. He can't say that but I can. They're understaffed, they're underfunded and they need more emphasis being put into training and all of that takes resources. And we have, we have cut $124 million from the DHS budget over last year.

Yepsen: Why can't you say that, Mr. Foxhoven? Do you need resources?

Foxhoven: Well, here's what I would say, that we're going to always try to work within the budget that we have. When we're given a budget it's easy as a manager to always say, well we need more people, let's get more money and let's do more. My job was to come in and take a look at everything that we do from top to bottom and say with the resources you have, can you make improvements? We can and there are things that we can do. I've been meeting with social worker II's, I have a meeting with some today and I will next week again, saying what can we get off of your plate? There's two ways that you can approach having people do the important work that they do. One is to get more people, the other is to get things off their plate that takes up their time and keeps them from doing the important work that they need to do. That's the first thing I'm looking at right now, what can we get off of their plate that is bureaucratic and troublesome that stops them from doing all the things they need to do?

Henderson: So, are social worker II's, not everybody may know who that is or what they do, are those the people who investigate when there is a claim of abuse?

Foxhoven: No, those are social worker III's. Social worker II's are the ones who work with the people once we remove a child, when they're in foster care or even if we don't remove, if we're involved, that work with them. So if we look, if I'm looking all the way back from fiscal year '11, let's say December of '11, fiscal year '12, we have lost a lot of people since then, 895 people. If I compare social worker III's, the ones who investigate reports, it's a little bit higher, that number is a little bit higher than it was back then. If we look at social worker II's they're down. What's really down are institutions.

Yepsen: Mr. Foxhoven, how much more money though would you use, would you need?

Foxhoven: Well, I'm not even saying that we need more money right now. What I'm saying is that --

Yepsen: Is that because you work for the Governor and she doesn't want people talking about needing more money?

Foxhoven: Here's what, no, here's what I would say is really important. Right now it's important for us to take a look at what we do and let our people get things off of their plate that eats up their time, that doesn't make any sense, and then we could be able to really assess if we added more people. Let me just give you a quick example. When I talk to the social workers, we contract some things out to other people, some services and stuff that traditionally case workers do. And one of the things those case workers are telling me, what if we didn't contract that out? What if we took that money and hired more case workers and let us do that work that we traditionally do? That's some of the things that we want to look at.

Yepsen: I get that, Mr. Foxhoven. Senator, how much money do you think is necessary, much more money is necessary?

McCoy: I think it's going to, I think it's going to take tens of millions of dollars. For example, we have 56 counties in Iowa with no child abuse investigator in the county. So we have 178 currently on staff, on the payroll today, most of them are working mandatory overtime just to do the basic things, 156 of them had overtime, of that group some of them had overtime that totaled $40,000 a year. So we need more people in the investigative role. Some workers are covering five counties.

Henderson: You mentioned systemic problems. Are you talking about people who are allowed to be foster care parents and changing those rules?

McCoy: So what I see as one of the systematic failures in the system is this outsourcing. We use a service, it's called KidsNet or Lutheran Social Services and they go out and do home visits. They're a part of the recruiting and retention process for foster care parents and adoptive parents. We need to insource that and have professional, licensed social workers doing those home visits. I think that is one of the things that Jerry has alluded to because the workers are telling me the work that is being done on the home assessments is failing and that is one of the systematic failures.

Henderson: Mr. Director, just real quickly, is that something you plan to recommend?

Foxhoven: It's something I plan to look at, we're looking at everything from top to bottom. And one of the things we have to look at, when we look at the two tragedies you mentioned at the beginning of the show, is how did these people come to get those kids to begin with? Who picked them out? And how do we hold people accountable that are recruiting and retaining those people to make sure that we get good people? One of the things that springs to my view right away is that Iowa has a placement change that is higher than most places, disruptions. Most states, we don't do as well, we do better than states, other states in many areas, this is an area we don't do real well at, we have a lot of placement changes. So my question is, is that because the social worker when they view that home say that's not a good home, that's not a good place, we need to move them? And if that's the case, then we should be building into any contracts, if we have other people recruiting, we need to build something in to make sure they're penalized if they recruit somebody that is not good.

Yepsen: Does this cutback on overtime pay, is this jeopardizing children?

Foxhoven: No it's not because --

Yepsen: Senator, do you think it is or is not?

McCoy: Well, I've been told that the department said that they have held the investigators harmless on the overtime rules. So, I don't think that will impact them. But what I will tell you is that in the case of Natalie Finn, I interviewed the case worker that was responsible for that case and was fired, and what she told me was that this year, the final year, she earned $20,000 in overtime pay because she was handling so many cases and that she had been at the hospital for 12 hours on another case with another child when she should have been addressing the Finn case. So, I think it is impacting their ability to perform, overtime is impacting them.

Rodriguez: Jerry, I want to make sure I understand, what level of transparency can the public expect from the department in terms of this is how we are making improvements, we're going to have a report by this date? What can the public expect?

Foxhoven: When we get a report from the group, the outside group that we have hired to do the review, it's going to be public, we're going to make that report public. They are just finishing up the first phase right now which is to drill down in what areas should we take a closer look at, they're not finished with that yet, they have one more visit before they get there and I think that visit will include legislators and others. And then they're going to say, these are areas that we think we need to look to more closely and that's when we move into the second phase.

Yepsen: I need to move on to another subject, way too many questions and not enough time. Medicaid, Mr. Foxhoven, did the state go too far in privatizing the management of this program?

Foxhoven: You know, no. Is it running perfectly? No, it's not. Is there work to do yet? Yes. I'm committed to managed care, the Governor is committed to managed care, I think most states are going to managed care, it's the right direction for us to go. We need to continue to make sure it's funded properly, we need to continue to make sure that we're providing oversight on the MCO's, the three companies.

Yepsen: What are MCO's?

Foxhoven: They're managed care organizations. The three companies that are managing --

Yepsen: Senator, do you think it was a mistake to go to privatizing?

McCoy: I think that the method that this was implemented by and the speed at which it was implemented was too fast and I think as a result the system is not working well. I think there is a segment of the population that never should have been under managed care and I think that is the long-term waiver disability population because those are individuals with severe needs and they are not going to get better.

Henderson: So why are you nodding, Mr. Foxhoven?

Foxhoven: I'm only nodding to say that is an area of the population that we continue to watch to make sure that we figure out how to serve them best. And that doesn't mean we need to remove them from managed care, it does mean that we need to figure out a better way to provide services to do that and we're in the process of doing that.

Rodriguez: This week you made remarks that indicated that that group may be exempt from the program down the road. Does that not give the message that maybe the state went too far in putting them into the privatized program?

Foxhoven: I think the reporter might have gone a little too far in terms of what my statement was. My statement was really more what we had just talked today which is that population we need to continue to look at it to make sure that we serve them the best. I didn't say we ought to take them out of managed care, I didn't say that we ought to go back to the old system. What I did say is we need to explore all the possible options with that population and we're doing that to figure out how do we do it. Now, if I had to guess how we're going to do it, they're still going to be in managed care, we're going to figure out a different way, a payment mechanism, a different way to make sure that they get the services they need.

Rodriguez: I want to make sure that I ask about the status of negotiations with the department and these managed care companies. The end result could be that the state is spending millions more than what they currently expect to spend.  So where are we? And why haven't we received the final numbers yet?

Foxhoven: Well, we're not, we don't have the contract signed yet. As Senator McCoy said earlier, I'm kind of pretty new in this deal, I've been here less than three months, and it has been a huge lift for us to get there. You have somebody else that is captain of the ship now and that means the negotiations kind of started fresh. I have higher expectations I think than what they were expecting and I expect good oversight, I expect good delivery of services to our people and good payment. And so as a result of that it creates issues in the negotiations. We've got a contract that is about a hundred and some pages long with the MCO's and so as we go through that contract and create clear expectations it takes time. We're moving forward. I had a meeting this morning with one of the MCO's in a negotiating session. So hopefully we'll have that inked pretty soon.

Henderson: You mentioned payments. There are health care providers around the state who say, we're not getting paid in a timely basis. How do you get that fixed?

Foxhoven: Well, first of all, I don't think it's as bad as everybody is saying. I met with a CEO of one of the providers just earlier this week and he came to talk to me about other issues. And I said to him, what is your payment experience? Because we're concerned about that, we're trying to watch that. He pulled out of his briefcase some documents and he said, he gave me the percentage for all three MCO's, okay, as to their payment rates and the lowest was 95%, the highest was 97%. Well that's pretty good when you talk about a quarter of all Iowans are on Medicaid. And so we're doing much better.

Yepsen: Senator, are you happy with what you're hearing here?

McCoy: One of the things that I see happening is we have audited financials that went into the insurance commissioner which indicated that the losses by the MCO's, the managed care organizations, were catastrophic and they exceeded $400 million. And with the establishment of the risk corridors and the additional commitments that these MCO's are going to require from the state, my question is, back to Miss Rodriguez's question is, how much is the state going to have to come up with? As I did a rough calculation on my envelope it was maybe $150 million of new money that is going to be required or the question is are these MCO's even going to be around if that new funding doesn't come in? And some of that is federal and some of it is state so I think it's really hard to understand what percentage the state is going to have to come up with. But we know it's going to cost us more money, at a minimum probably $40 million.

Rodriguez: I just actually also want to ask something about Medicaid regarding something that is called retroactive benefits. Essentially the current system allows an individual to receive back pay if they have a sudden illness. There are hospitals now that are saying that if the state moves forward with this cost containment, as it was described to the legislature last session, hospitals are going to be footing the bill for individuals who are suddenly brought to the hospital for care. What do you say to those health care providers that say you're not cost saving, you're cost shifting?

Foxhoven: What I would say is this, is that really isn't as simple or as clear as people make it sound. First of all, when you qualify for Medicaid it goes back to the first of the month. So here we are in the middle of September, if someone qualifies for Medicaid, they get coverage from the first of the month. So if they're sitting in an emergency room we're going to pay those bills back to the first of the month. Under the way it was previously done they would pay all the way three months back. And let me think, let me have you all think about Medicare, for instance. In Medicare, when you qualify and you come in for a claim on Medicare and you purchase your Medicare insurance or you get Medicare insurance, they don't pay your bills, if you did that today they don't --

Rodriguez: Medicaid is a safety net.

Foxhoven: And so is Medicare, and it is a safety net because when you qualify we go back to the first of the month. The question is, does it make sense to go back three months before you even applied for Medicaid.

Rodriguez: If the federal government approves this, Iowa would be the first state to cut these benefits for its entire Medicaid population. I mean, that has gotten, that has raised a lot of questions again from health care providers that this is going to be astronomical in terms of the costs that are going to be shifted to hospitals and to patients. Again, what do you say to them who express serious concern about this?

Foxhoven: Well, again, if you're looking at a hospital I want you to really think in your own head, how many people have been in the hospital for three months before you even applied for insurance? I think that number is pretty small. And so it's really hard for me to imagine that the hospitals are full of people that haven't applied for, they've been in there for three months already, there aren't even very many people in hospitals for three months anymore, who haven't even applied for insurance yet that they need to go back. Again, we will continue to go back all the way to the first of the month.

Henderson: Let's go to another segment of the Medicaid population, those who are seeking contraceptive services and cancer screenings. As of July 1st they may no longer get those services at a Planned Parenthood facility or any facility which offers abortion services. Can Medicaid patients in Iowa find a provider today?

Foxhoven: Yes, and so far that has been our experience. I think there has been a survey or something done by Public Radio where they came out and said, yeah people seem to be finding services. We're not having people contact us and say, I can't find a provider. That's not what we're experiencing so far.

Yepsen: Is that what you're hearing, Senator?

McCoy: I am actually hearing that it's very difficult for women in rural areas to find access. So that is what I have been hearing.

Rodriguez: I do want to make a really quick point that Des Moines County in the Burlington area is actually moving forward with seeking separate federal dollars in order to create a new clinic because they feel that now that the Planned Parenthood clinic in that region closed they don't have a one stop shop for the other reproductive health services that individuals are seeking. So how do we have a situation where you've got county officials in one corner of the state say that this new system isn't working?

Foxhoven: I think any time you have a situation where a particular provider is no longer available, like for Medicaid people Planned Parenthood, other people will fill in that gap and taht's what is happening. So some private sector, hospitals and so forth, provide services that maybe they wouldn't have provided before because they have Planned Parenthood to compete with them. And that is what's going on here and that’s kind of pretty natural and not a surprise and actually it's a good thing that other providers step in and say I'll fill any void so that their services are available.

Rodriguez: A quick question, Senator, with Medicaid privatization there had been an effort from the legislature to have oversight on how that was working out. Does the legislature need to step in again to ensure that the data that is being collected on how this program is running is working?

McCoy: Yes, except the legislature, the republican-controlled legislature, are not calling for oversight meetings despite repeated requests by democrats to have these meetings and hold these meetings and receive this testimony and it's simply not happening.

Henderson: Mr. Foxhoven, your agency oversees institutions which care for juvenile delinquents. Disability Rights has raised questions about the conditions at Eldora. Can you assure parents and people who care about those kids that are in Eldora that they're being treated appropriately?

Foxhoven: Yes they are. And we don't get any complaints from the juvenile court officers who are assigned to those cases, from the attorneys for those kids, about the services that they're providing. I've looked at it very closely. We're doing a good job. Are we doing perfect? No, these are very, very, very tough kids to serve.

Henderson: The group raised some of the same concerns that were raised about the home for girls and it was closed. You were involved in the review of that. Why isn't this being closed?

Foxhoven: Because this is way different. The reasons for closing the Toledo facility had a lot to do with the fact that we combined populations that should never have been combined. This was a training school where we put abused, neglected kids in a training school. They don't belong -- we combined girls and boys in a training school. They didn't belong there.

Yepsen: We've got just two minutes left.

Rodriguez: I just actually also want to ask about these crisis centers that are situated around the state that help with mental health services. There have been some reports that while these centers are being praised for the work that they're doing, they're at the brink of closing, in part because the Department of Human Services is not moving forward with administrative rules that could ensure that they received Medicaid dollars. What is the status on that? When can we expect to see the department do something on that?

Foxhoven: Well, the complaint about some rules that apparently hadn't been passed for a long, long time. And, again, I've been here three months and I've made it a priority for us to get those rules done. The rules for the service, the types of services that are required, those rules are there. We're talking about services that we think are good that are not required by law and we want to get that done and provided. Also there are some other options that some of the regions have tried to do to fill in that gap, to provide funding to some of those places. Some of those places haven't been willing to participate.

Yepsen: Senator, we've only got a minute left. I'll give it to you. What do you expect this coming session of the legislature to do with this? Anything?

McCoy: Well, I'd like to believe that we can find some bipartisan cooperation and work on the issues. For example, making sure that all foster kids and all adoptive kids who received a subsidy from the state have a physical every year, have a dental check. In addition, I'd like to see us do some real case study on insourcing our home visits to make sure that we're putting kids in safe places. And the third thing I'd like to see us do is really evaluate our resources at the state level to determine if we are overstressed as a system and if we can improve the way we exam the more than 50,000 calls that come into our call center every year to report abuse.

Yepsen: What is this going to cost? I asked you earlier, add it all up for me. And where does the money come from?

McCoy: I think it's going to cost millions of dollars and I think that the priorities of the legislature are going to require us to redirect funding so that this becomes a priority. Our children should be our top priority as a state and protecting them is our greatest obligation.

Yepsen: We're out of time. Thank you very much, both of you, for taking the time to be here today.

Thanks.

Thank you.

Yepsen: And we'll be back next week with another edition of Iowa Press, Friday night at 7:30 and Sunday at Noon on our main IPTV channel with a rebroadcast on our .3 World channel Saturday morning at 8:30. For all of us here at Iowa Public Television, I'm David Yepsen. Thanks for joining us today.

(music)

Funding for Iowa Press was provided by Friends, the Iowa Public Television Foundation. The Associated General Contractors of Iowa, the public's partner in building Iowa's highway, bridge and municipal utility infrastructure. I'm a dad. I am a mom. I'm a kid. I'm a kid at heart. I'm a banker. I'm an Iowa banker. No matter who you are there is an Iowa banker who is ready to help you get where you want to go. Iowa Bankers, allowing you to discover the genuine difference of Iowa banks.