All right.

Good morning.

I'm at large councilmember Christina Henderson, chair of the committee on health.

Today is Monday, May eleventh, twenty twenty-six.

The time is ten oh three a.m.

We are in room five hundred of the John A.

Wilson building.

However, the uh hearing can be viewed live on cable channel 13 as well as on my YouTube page at CMC Henderson.

This hearing was rescheduled from its original date on April 29th.

Um, this is part two of the budget oversight hearings for the proposed FY27 budgets for the office of the deputy mayor for health and human services as well as the Department of Healthcare Finance.

Uh, Deputy Mayor Wayne Turnage, who wears two hats as the deputy mayor as well as the director of health care finance.

Um, we're going to start with DMHS, and then we'll move to health care finance thereafter.

The Office of the Deputy Mayor for Health and Human Services supports the mayor in coordinating benefits, goods, and services across multiple agencies to ensure that residents with and without disabilities can lead healthy productive lives.

DMHHS manages two special initiatives, age-friendly DC and the Interagency Council on Homelessness.

They also oversee the administration's encampment clearings and cleanup efforts.

The Department of Health Care Finance provides health care services to low-income children, adults, and elderly persons with disabilities.

More than 290,000 district residents, approximately 40% of all residents receive their health services through DHCF's Medicaid and Alliance programs.

I don't see any of my colleagues with me now, but we'll certainly turn to them should they uh join us.

Um Deputy Mayor Turnage, before you begin, um I need to swear you in as well as anyone on your team who may speak today.

Just makes it more efficient, so if everybody could raise their right hand.

Do you swear or a firm under penalty of law that testimony you're about to provide to the council of the district of Columbia and this committee is the truth, the whole truth, and nothing but the truth.

Great.

Um Deputy Mayor, when you're ready.

Uh good morning, uh Chairperson Henderson and members of the committee.

I am Wayne Turnich, Deputy Mayor of Health and Human Services, and the director of the Department of Health Care Finance.

I am uh here as you've noted to briefly report on the fiscal year 2027 budget for um the deputy mayor's office um and later the department of healthcare finance.

But before I begin, I do want to thank you for uh your kindness in rescheduling this meeting to allow me time with my family.

What has been a difficult past few weeks?

So your thoughtfulness is uh very much appreciated.

As is custom, uh I will start with the uh budget for the deputy mayor's office.

Um, and as you know, that's just very small operation, just over two million dollars.

I am joined by my uh team, a wonderful team of uh the chief of staff, Rachel Joseph, and uh policy director uh uh Brian Harrison and the uh gentleman who uh expertly runs our encampment program, uh Jamal Wilson.

Um we have submitted written testimony.

Um it is uh as you noted a very small budget.

The most significant quote consequence has been the um uh defunding of the ICH function.

Um and if we can um if you would like a summary of the budget highlights, Rachel Joseph can prepare such.

Otherwise, we can go straight to any questions that you might have given the small nature of the budget.

Okay, all right.

Um, so we'll get some questions in.

I don't have that many for our DMHHS.

Um, so deputy mayor, let's actually start on interagency council on homelessness because that is the biggest change in this particular budget.

Um the proposed FY27 budget reduces the ICH staff by seven FTEs, um, five of which are currently filled.

Um these positions are currently located within the Department of Health and Human Services budget.

Sorry, Department of Human Services budget.

Um at performance oversight, DMHHS testified that you had just brought on four new ICH staff to kick start the update to its 2024 priorities.

Um, starting to what changed?

Um, what changed was the uh the lack of dollars to pay for the positions.

Um the um agency that funds those positions under significant stress and given the uh of the challenges that they had.

And so we at the end of the day decided that uh we should um do the best we can to preserve as much as we can of the uh funding agency and as a result those positions were eliminated.

Okay, so after these reductions take effect in October, how many FTEs would be remaining if the council made no changes?

I think it's one Rachel's has been.

It's one FTE.

And just to add, it would be the director of the ICH.

Okay.

Um, though we do also have two vacant positions in DMHHS that we could repurpose to support ICH if necessary.

Um, I do want to add you had asked about the strategic plan for the ICH, that they expect that to be done um in June.

Um, it gets goes to the ICH full council at the June meeting.

Um, and so the staff who are were brought on, um, three of them were brought on in NTE positions, recognizing that they could be potentially um short-term positions um to support the work to get us through the end of the fiscal year.

So um we anticipate that the strategic plan will be completed with the help of the staff before we have to um get rid of the review.

Okay, all right.

I'm also being asked that you guys um either move the mics closer to you or speak a little bit louder.

Um, are there federal requirements for the ICH regarding reporting and data analysis?

And are we concerned that I mean only leaving the director would impede that work?

Yeah, I'm not aware of the specific federal requirement, but we do have, I mean, I don't want to dismiss the difficulty that um, you know, it that the ICH director will have and continuing to do the uh kind of work that uh she has expertly provided.

It will be a challenge with no staff, and frankly, we will have to huddle with her to see how um we can best move forward in the absence of the support that she customarily has.

Okay.

The proposed budget for DMHHS transfers one FTE for a senior advisor position from DMHS to the deputy mayor for education.

Um in your pre-hearing responses, you all indicated that this position was already located within the DME and that this budget is reflecting where the position really lies.

Um, why was it originally placed with DMHHS?

So this happened prior to my coming on as chief of staff, but my understanding is that it was a mistake in moving the position moved from the city administrator's office and it was supposed to move to DME, but somehow it was put in our budget so that the person has been sitting in DME working for DME, um, and this just reflects putting the position where it rightfully sits.

Okay.

Yeah, this is just sort of a reflection as somebody who um used to spend a lot of time on the deputy mayor for education's budget as the committee director for committee on education.

The health and human services cluster has a larger portion of this government's finances, and you have less people coordinating that work.

It's called efficient.

Oh, okay.

Okay.

Um, so you all proposed two new FTE positions, a public affairs specialist and a data visit data and visualization specialist.

What would your public affairs specialist be doing?

So those are positions that were created again prior to my coming on, and we have used them.

We we haven't filled them because of um mid-year cuts for vacancy savings.

Um, and I think that the truth is that it probably would not be a public affairs specialist um once we go to fill it.

It's not a new position.

Okay.

Um, I think that was incorrectly indicated in the pre-hearing responses.

Um, it was there for this fiscal year.

Um, and when I came in and started assessing what was the staffing in the office, I decided that we did not need to fill that immediately, and we could use that those vacancy savings for mid-year cuts.

Um, but the position having the position um to be able to adjust, um, and as you mentioned, uh, we have we function on a very small staff, um, but having that position to be able to create um the the workload that we need, even to support the ICH, um, potentially to support the fact that we don't have um a director position at health care finance, so that that is um the plan for that position.

I mean, I'm not picking on you guys in terms of that all together, but this is something I thought, right?

Why does every deputy mayor need their own comms person, in addition to every agency having its own comms person, in addition to every agency having their own data and visualization people, you also need one of the deputy mayor's.

You see what I'm saying?

Like the redundancy.

The data and visualization person was specifically for um ICH purposes.

Oh, okay.

So I think, you know, if the cuts move forward to the ICH, um, that would probably be a good repurposing of that position to support.

I don't know whether it would be specifically data and visualization or solely data and visualization, but to support Director Silla.

Okay.

So they tell us America 250 is happening and we should celebrate.

Yay, America.

How are you all planning for this summer and expected higher scrutiny on encampments by the federal government?

That's a very good question.

There has been a obviously a um a subtle shift in our strategy over time.

Um we um were basically trying to manage encampments to keep them from becoming um challenges for both the residents uh in the encampments and the residents of the city.

We tried to move people out, but if we didn't, we wanted to make sure the encampments were uh clean uh and the residents living in those encampments were safe.

Um we've shifted their posture uh with the expansion of uh shelter beds.

So with the ability to now offer a shelter bed uh for every person who is living in an encampment.

We take the position that uh campments encampments are not should not be allowed uh on the uh streets of the city.

So um Jamal and his team uh will be uh as they have been seeking to um close encampments where they encounter them and do all of the pre-uh closure work, pre-cleanup work, uh, with the goal of getting people to move to shelter.

Uh will we close every encampment?

The answer is obviously no, because some people just don't want to go inside and they will just move to another location and create uh another engagement for Jamal and his team.

So uh we do expect greater scrutiny this summer.

Um, and we are you know, frankly, a little worried about how that scrutiny might play out.

So uh and I'll let Jamal address, you know, what they're doing and how they're doing it, because he is um he and his team are just excellent at what they do.

And um, but we are a little concerned that um, you know, we with the uh the emphasis on uh the birthday of this country, the 200, I guess it's 250, that there could be uh a push to make sure the streets are absolutely free and clear of all encampments, and that's a heavy lift.

Uh, we will do what we can prior to that time, but it will be difficult to um close every encampment and move people into shelter, particularly in the summertime when they don't want to go to shelter.

Jamal, you gonna add anything?

Yes.

Uh good morning, and Councilwoman Henderson and all.

Um, with the encampment team and myself, what we are looking to do is still continue our collaboration with our interagency partners to work towards the outreach of, as the DM stated, uh advising residents and urging them to seek shelter and a variety of other connected services as may be applicable to their situations.

Uh, we're going to continue to identify locations at the highest health and safety concerns, of course, first and foremost, those that are uh impeding certain areas of the city from their intended use or causing again extreme safety concerns such as fire hazards, different things such as that.

Uh our biohazard team will still continue to work with us to address uh certain issues intermittently.

Uh we try to mitigate um as much as possible having to um be uh too frequent with any particular site.

We try to work with the uh outreach partners to see if there's anything that we can do to support their efforts that would be more successful.

What we have seen over the past, I'll say four to five years, is definitely a significant drop in the number of encamped residents.

Uh we're currently tracking in the mid-80s of encamped residents, whereas about three years ago we had well over 120.

Um, same thing with our sites.

Our sites have decreased to about mid-60s, where we had at one point over a hundred physical addresses uh throughout the city.

And many of those locations that are currently residing in the district are more so one or two residents per encampment uh as opposed to the larger um 10 plus that we had experienced years past.

So we're going to continue with that effort and see how best we can support, of course, the service effort, but also addressing the health and safety, health and uh safety concerns.

I mean, 60 locations still sounds like a lot.

It is still significant, but if we go back to again about three or four years ago, we were well in the hundreds.

Actually, in around that time, we were closer to 200 residents on average that were living in encampments.

So I think we have seen a significant decrease, but a lot of that has gone to one, the consistency of our enforcement of the protocol, but also the human services efforts with our community partners, uh, our um interagency partners, DHS, DBH, and being able to connect those residents while building the report to their uh viable resources.

Okay, if you recall, um we had one encampment, like 75 people in it, um, and we closed that.

We we closed the four largest encampments in the city.

We did it humanely, we did it with the emphasis on putting people actually in apartments.

Um, and um when for the first three, I think we we s we'll put over 100 people in apartments.

I was gonna ask you about that in terms of I guess we we called it a pilot.

Yeah.

Are we still tracking those individuals?

Well, yes, uh, still tracking uh 115 individuals that were housed and still receiving services uh with care.

The primary tracking of that does fall under our DHS partners.

Uh but yes, that pilot did uh turn out to be very successful with our efforts.

Uh there were four major sites that were connected to that, and the residents who agreed to services we were able to assist.

How many of them are still housed departments?

The last check that I had there was still a hundred and fifteen, but I would have to follow up with our DHS uh partners for accurate count.

Okay.

Um, Deputy Mayor, during performance oversight, you testified that you guys um were working with the mayor to consider removing the cap on the beds filled at the Aston.

Um I talked a little bit about um I guess our bridge housing strategy with um director Pierre of DHS.

So we have the Aston, we have E Street, which is not at capacity, and then there's funding in the budget for a third location that site yet to be identified.

Is that an accurate representation?

Yes.

Okay.

Um what's the word on the Aston?

Uh I would say that the the concern about expanding that uh still remains.

It has been a very successful program, and we have not been able to overcome our concerns that if we expand it appreciably, that it may be difficult to uh uh it may be difficult to manage.

And so I think until you know we are comfortable with the notion that it can be done and done in a way that does not create problems for the residents in the Aston and surely in the surrounding community.

Um there will uh not be a push from the uh mayor's office and the deputy mayor's office to expand the number of uh uh beds there.

Okay.

Uh then what where status on a third location, yeah.

I am to be honest, I have not been intimately involved in the site location DMHH, I mean DHS and the CA work very closely on that.

I think we I know there were a couple of sites that we contemplated and they were just too big.

Um, and I'd I'd have to touch base with the CA, or maybe Rachel knows what the next site um you know, might be on the agenda.

DGS has a um broker that is supporting them in trying to find locations, and we've been looking at them as they come up and um so far there as the deputy mayor said that we haven't found one that has the right size and the right configuration.

Okay.

I guess I'm curious in terms of the thought around a third site when the first two are not at capacity.

Well, uh I think the best way to look at that and I understand your concern is it's not a concern, it's a question, right?

I mean, like in terms of like it's it's a legitimate question.

The uh the um what we are our position currently is to get to capacity in that site would be a could be a challenge, uh, not in terms of the ability to put people in, but the ability to manage it.

So we kind of treat it as being a capacity from a programming standpoint, and if we decide to go, you know, to a larger uh number of bears, then we'd have to uh sort of resolve you know the challenges that could come from expanding that site to you know more than 100 beds.

I don't know.

I guess my question is for E Street, is that also going to have a 100 bed cap as well?

Because what I don't want to happen is sort of people feeling as though Boggy Bottom is getting special treatment.

Does that you get what I'm saying?

No, I hear you.

I and uh I don't think there's a um a capacity limitation at E Street.

No, and they're on their way to them working hard to fill those beds.

Yeah, yeah.

There's an infrastructure issue that they've dealt with and a programming issue uh that you know they feel they're ready to uh uh deal with a larger number, so that those beds will be full uh filled.

Okay.

Um in this same vein, something that came up um at the DHS hearing was around bridge housing is supposed to be temporary, but the way that the current budget is set up, we have no place to send someone to after they reach their cap or not cap, but a lot of time in bridge housing because the budget doesn't include any new money for vouchers.

So, you know, what what happens next?

You know, I will sort of defer to the experts at DHS.

That is a uh sticky uh issue, a very real problem.

Um, and so what rather than um opine about what I think will happen, I will uh certainly uh talk to Director Pierre and get her views on how they will manage that situation uh because it occurs not only in bridge housing, I think it occurs in the short-term family housing as well.

So they that's something that they struggle with on a regular basis.

Very complicated problem.

It's probably the most I don't say probably in all my years.

This is the most difficult public policy issue that I've ever had to confront.

Housing, huh?

Housing?

Yes, housing, uh encampments, um, you know, shelter living.

It's very challenging uh for a number of reasons.

And you know, the district probably spends more per capita on these services than any city in the country uh per on a per capita basis.

And it always feels as if we're not doing enough, and so I have to remind myself that if you go to other cities, they don't have anything close to what we're doing, but yet we feel sometimes that we aren't doing enough.

Um and it's because the problems are so intractable, and you're dealing with human beings who are uh living in some very, very tough situations.

So yeah, it's it's by far the most challenging public policy issue that I've ever faced in 40 years of working.

Okay, um, sort of in that same vein, I want to ask you about C C and V.

Um so a few weeks ago I was uh talking to the leadership over at Unity Clinic, and one of the concerns that they raised was that the plans for the new CCNB would not include a health clinic on site.

And I think there might be some tensions there between the C CMV folks and then us.

Um but uh if we do our own sort of take a few minutes virtual survey of the area, if there is no health clinic on site, it is a very long distance uh for someone to go to the next closest, whether it be FQHC or something to that effect.

Sure.

Um can we commit that DMHS will continue to um monitor this project to ensure that the health clinic on site.

I mean, I know it's a partnership, but like we should have some say here, no?

Yeah, I think it would be a mix a mistake if there's no health clinic there.

Um the um the uh rather um trenchant um differences on this between the health clinic and uh CCMV, I think will be resolved.

I think they have to be resolved.

And and um I think it the model should include a health clinic from my personal view.

And so I certainly will uh to the extent that I have any influence.

Uh I will try to use that influence to um make sure there are some services as health services in the facility.

Uh and I think, you know, it's right now people are in their own corners.

But my hope is that um as we get closer and closer to uh to move from design to bill to operation, that whatever differences exist about whether or not there should be a clinic that can be amicably resolved.

Okay.

Um so my staff has been participating in your regular meetings with uh the leadership and staff at St.

Elizabeth's hospital to address some of the ongoing um concerns and challenges at that site.

Um, regarding staff safety and patient safety.

Um from your perspective, how have those meetings been going thus far?

Oh, I think they've been going extremely well.

Um we've given money to address some of the infrastructure issues.

Uh I think the reprogramming is probably with you, if not.

Um, it's been Nolan knows where to reprogram.

It's gone, it's gonna be.

Oh, remember, oh Adrian from a high AFO comes through.

Uh, it's been against it, right?

I think I think we've I think we've we're doing really well.

We're not done, but they've made tremendous progress.

Uh Dr.

Basron and uh Rachel have uh been uh just doing a wonderful job.

And the uh the staff at uh at that we've met with at the hospital, they seem to be in agreement that we we're seeing significant progress.

More work has to be done, but I think if you bought that staff in and had another hearing, it would be very different than the one you had some time ago.

I think they might appreciate the fact that there have been conversations, but the resources aren't necessarily flowing in the same way.

I mean, it was a it was a surprise to me to get the budget and see a 14 million dollar reduction for St.

Elizabeth's hospital in the budget, not additional resources, but right, yes, vacancy savings and also they've got need for new systems.

They still have a bunch of hiring that needs to happen, and in the interim of hiring, they should be hiring a contractor to get on some of their work order backlog.

Um they have a need for additional security.

Like, I mean, you know all of these.

A bunch of those issues are being addressed.

Um, Rome wasn't built in a day.

I mean, if there were.

But Rome also had some money, no?

I mean, like, I think we've made, you know, I I do think we've made some significant progress.

Like I said, there are things to be done.

Uh on the hiring front, I think that um we've made significant progress on hiring.

Rachel, you can you have the details, uh, but when I sit in those meetings, I get a sense from the staff, my staff and their staff that they uh that they like the progress that's being made and they want to keep pushing for more.

Rachel.

So they have made a significant uh have made significant progress on hiring.

I don't have those exact numbers with me right now, but I'm happy to share them, although your team is participating in the meetings and knows.

No, I got the the the slide presentation um during their hearing, yeah.

I do think there um there's some frustration at the moment that we don't have the next meeting scheduled, um, and that um I would request some grace from the folks at St.

Elizabeth's given what the both the deputy mayor and I have experienced in the last few weeks.

Um we will get that scheduled as soon as he is back full time in the office, um, and we will get back on a three week every three week schedule.

There just have been a variety of personal reasons that um we've had to either cancel or reschedule, and I know that the staff over there are pretty frustrated about that, and I will um make sure that we get that back on track.

Yeah.

I mean, frustrations understood, but sometimes frustrations are just from lack of information.

So yep, you know, if we just communicate with folks.

Now, Deputy Mayor, on the same vein, um, well, it's it's a little bit different, but I want to ask about SNAP and Medicaid work requirements.

Um SNAP work requirements will start in effect in June.

Medicaid will start in January.

And I still have community partners and providers who are looking for information of how to support their um clients through this time.

Um I'm told there's working groups happening, right?

I'm told people are meeting and having conversations about how best to do this.

Um, and yet it's May 11th, and there still has been no external communication with the people who are closest to the very clients who we want to ensure are able to keep their benefits.

And I think it's so important, particularly on the Medicaid side because once you lose Medicaid, there is no safety net after the safety net.

That's correct.

Like there's no other program that we can say slide you in, and I doubt that this administration is going to attempt a TANF local local situation when it comes to Medicaid.

That's that's that's accurate.

Okay.

So let me say, and and you know, we this is a lot of questions for a two million dollar budget, but you know, we we get you have responsibility of the whole cluster.

I know you don't like that, I know you don't like it, and yet but let me say on the Medicaid side, uh Melissa Byrd, and she can talk about this when DHCF is up.

She is heading up a very, very um detailed um project process that will uh result in us standing up a uh a work program that is broadly communicated about um um how you meet the work requirements uh for the Medicaid program uh now.

Right, that's in January.

That's in January.

And I have a lot of faith in Melissa.

Yeah, you should pay her more but the point still being is that SNAP starts first.

Yeah, SNAP starts first.

Uh and you know, I you know, I hate to be a pessimist.

Um but the city will have challenges with both work requirements because of the exemptions that have existed in the past.

Um, so you have population that benefits from SNAP into uh a lesser degree Medicaid um that have uh been given grace about um not having to pursue uh work requirements.

So that is whatever process we put in place, however much it's communicated, we have to overcome that that factor.

And I think that that is a challenge that people should be concerned about.

We will certainly do our absolute best to make sure people know how to interact with the system to report their work requirements.

But my concern is there will be many people who will not meet the work requirements, not because they don't know how to interact with the system, so because they don't have the appropriate work activities.

Right.

That's my part in terms of my understanding is that there's been some work group going on with Department of Employment Services, Department of Human Services, etc.

And the and and the city administrator, I've not been here for the last couple of weeks, but they've I've glanced at the calendar with the several long uh uh work requirement meetings, and I've in fact I will need to get up to speed when I come back to work uh next week uh full time.

I'll need to get up to speed with both uh Melissa and her team and Director Pierre and her team on sort of sort of so what the uh scope of work is and where we are in the process and how we will uh monitor our progress to make sure on the administrative side there is no failing.

Uh but again, we can do everything perfectly and still have a large number of people who don't qualify because of reasons we cannot control.

Well, we will work very hard to make sure that the number of people who ideally we would like nobody to lose benefits uh on the Medicaid or the SNAP side because they fail to meet a work requirement.

So that is our goal.

I think some of the you are correct.

Some of it are the things that we can't control.

Some of it is around expectation setting.

Um, we had this conversation when we talked about TANF, right?

And and and doing the step downs.

People don't actually think that we're gonna do it.

Correct.

So they don't take the necessary steps because they're like, oh, well, they've been saying that they're gonna do this for 10 years now, and they ha never have.

And I feel like this is gonna be kind of a shock for folks, especially if you are relying on all three benefits.

You you have to have something to hold on to any of them.

So the Venn diagram of who would lose benefits for all three, is there's not overlap because TANF the SNAP requirements are for people without dependence, TANF would be with dependents.

So it's a much uh there's more overlap between the Medicaid and the SNAP, and we are very focused on that, very focused on trying to identify who those folks are.

But the TANF one is sort of a it is a concern, but it is separate because it's not it those are folks with dependence.

Um, so that's just one clarification to make.

Um, and we are DHS um and the team have been working really hard on the communications.

Um Melissa can speak more to this when DHCF comes up to testify, but they have um a new contract in place for communications.

DHS is gonna be using that also.

Um, and we have some work that work products that are due this week to the city administrator to be able to identify and understand who the affected people will be, um, and it's on a rolling basis, which helps a little bit.

You know, it's not all at once all at once, right?

Um, and there's a three-month grace period, like so you go in and you recertify for your staff benefits at that point, you're told you have to meet worker volunteer requirements, and you have three months in order to get into that um into that position um posture, um, and to show that you can so that we can certify that you're either working or volunteering.

Right.

Um, so that gives us a little bit more time than the June the it's not a hard and fast June first uh start date.

Um, and we are working very closely with um DME, um, DOES and SERV DC to make sure that we have the structures in place um so that as uh folks come in to recertify, they are being put into the pathways that will um help them maintain their benefits.

The problem on the Medicaid side, and I haven't looked at the um work requirement regulations in a while.

Um, but as I recall when I first looked at them, the thing that alarmed me was uh for for new applicants.

I think they already have to have the work requirements met before they qualify when they first apply.

So the communication, if that's still true, the communication will have to be extensive because you could just come to apply for health care benefits thinking that I'm eligible, I need health care benefits.

I've lost my insurance because I've had a drop in income and lost my job.

I'm just gonna go show up and apply for health benefits, and then if the we calculate how much time you spend in the work activity and you don't you haven't done that prior to coming to apply, I believe you are you will be um uh not eligible.

So that's something if that requirement still exists, we have to figure out how we can tailor our communications to make sure people understand, even though you don't need um Medicare at the moment, if you think you you're gonna need it, you these are the work, these are the work activities that you need to be able to uh uh show if you're not exempt from those activities.

Okay.

Um final question on the DMHHS front.

So um, as you may be aware, the Office of Planning's budget proposes to zero out the Office of Food Policy, as well as repeal the entire food policy council, which is made up of volunteer experts who serve the city.

Um we've had both for the past decade.

Uh if the council were able to restore this cut, um we would likely relocate the office out of office of planning because it's very clear that the Office of planning does not believe that food policy and the Food Policy Council's work, do you believe that DMHHS would be an appropriate location for it?

To be honest, I'm not very familiar with their work, but certainly given our focus on making sure people don't go hungry in this city.

Um, if that is a the will of the council to locate it in the MHS, uh, either me or my replacement.

Um, you would welcome the uh challenge.

Great.

All right.

Um, we haven't made a decision there yet, but um, it can't stay at OP.

It has to move.

Um, all right.

That's all the questions I have for DMHHS.

Um, let's do a three-minute break really quick so we can switch out and then um we'll get to health care finance.

Um, thank you to the DMHS folks.

Okay, we're back for the portion on Department of Healthcare Finance.

I'm just gonna say at the top, Deputy, no, Director, now Director.

Director Tarnage now.

Um, and also for the purposes of the public.

Um when we reschedule the hearing, my staff and I had a very long um conversation with Healthcare Finance staff in advance of this hearing.

So if you feel like we're not pressing enough or asking enough in terms of questions, a lot of our questions we did get answered.

There are some things that I'm just gonna say for purposes of um, well, you aren't there, Wayne, but everybody else who is there.

It is going to be a repeat question, but it is a repeat question because we want to make sure that we get the response on the record.

Um, our meeting was not on the record.

Okay, Deputy Mayor, when you're ready.

Oh, just got to turn your mic on.

Good morning again.

I am uh it's my pleasure to report on the mayor's proposed fiscal year twenty twenty-seven um uh budget and financial plan for the District of Columbia.

I am um joined by my uh very experienced and hardworking team, both at the table and in the room.

Uh, as you know, Melissa Bird is our senior deputy and Medicaid Director.

We have uh a wonderful new interim senior deputy for finance who now steps in the considerable footprint that was left by the departure of uh Angelique Martin, but I can tell you having worked with April closely.

Uh she has big feet, and we'll step in that footprint very well.

Um, Eugene Sims is around here somewhere.

He's our policy director, and he's our go-to guy on any question that we get.

And sometimes when we tell you we need to get we need to, we need a minute to answer your question.

That's generally the time we are trying to run down Eugene.

Lots of experience with managed care, uh, which is very helpful.

And of course, we have uh Melanie Williamson operating in a dual role, both as uh my chief of staff and the chief operator, uh, chief operating officer.

And around the room, our uh our administrators and other staff with various subject matter expertise who may be called to the table uh depending upon the questions.

Uh we have uh labored long hours, uh, as we always do during this time, working with our tremendous agency fiscal officer, Darren Schaefer, and uh to analyze and put forth written proposals to the uh mayor's office that they uh evaluate, send back to us, tell us to do more, and we do that until we come to a budget uh that you uh uh had the pleasure of receiving uh when it was submitted.

I will start by going to slide four uh because I think it's always helpful uh to um sort of set the tone for um the challenges that uh the mayor faced in putting this uh budget together.

Um the um, and it had multiple challenges.

The most formidable was the existence of a citywide 1.1 billion dollar budget gap, which I believe is historic.

I don't think the budget gap has ever been that large.

Uh and we calculate the budget gap by uh looking at the previous year's approved budget as a starting point, and then we determine what it would cost to do that same those same policies and programs, uh what it would cost in the uh uh next year's budget, and that was a uh 1.1 billion dollar budget hole.

If you look at the graph on page four, we you can see that the principal reason for this problem was a um $700 million decline in revenue, which was a function of slower revenue growth, smaller forecasted uh and future revenue surpluses, and of course the decline in uh the federal workforce.

And and then that's just on the revenue side of the budget.

The expense side actually exacerbated the problem because the um projected changes for that side of the budget would have added about 450 million dollars to the approved budget if left unaddressed.

So, what did the mayor do?

She submitted a budget of about 11.8 billion dollars, which is 95% of 95% of the uh 20 uh 26 approved budget, and she did this by um uh very strategically uh producing about 800 million dollars in savings, and then there was some revised uh revenue estimates, uh some additional surpluses and some other small changes.

And as a result uh of that effort, uh the historic budget gap was closed.

Um I will uh turn to the next slide.

Um, and you know, we've gotten a lot of questions about um what it will take to put alliance back like it was.

I think what needs to be recognized is how much work was done to stave off the additional alliance cuts that were already in the financial plan for this year with the uh the mayor was able to maintain eligibility for adults uh uh who who are um a greater than 24 percent of federal poverty who were slated to be eliminated.

She uh maintained eligibility for adults in fiscal year 27, who only had uh one-time funding in fiscal year 26, and those were those who were newly enrolled in 26 between the ages of 21 to 26, and also enrollees who turned 21 in fiscal year 26 and and AIDS out of the children's program.

Those populations were all subject to lose their benefits, uh, but the mayor's efforts um uh were um uh instrumental in in her budget and keeping those benefits intact.

And as you know, you were uh sort of leading the way on the uh notion of reinstating dental envision benefits and those things were done, and um the total cost to reinstate um was about 30 million dollars in local funds.

If you go to um the next slide, you know, we um one of the challenges with Medicaid is always the local uh a projected local cost increase because of factors that uh if you're gonna have a Medicaid program, you can't um easily control, and that is you know, rising prices with providers, you know, given our eligibility level, uh there'll be pressures on the eligibility uh on the enrollment side.

Um we don't expand benefits a lot, but the benefit, the price of those benefits uh do change even if we don't add new benefits.

And so um there was a hundred and seventy-two million dollar gap across Medicaid uh or uh a spending, a projected spending growth, most of which was in DHCF, uh 19% of which was in two other agencies.

And if you ask the question, you said, well, 172 million dollars in DHCF's budget is it's not insignificant, but it's you know it's a $5 billion dollar budget.

If you um, if if you take the 172 as and for what it is as is a local um supplement, and gross it up, as Darren would say, to what it would cost when you include federal dollars, and that's 860 million dollars.

So if we did not fund that those those those spending uh increases, it would have taken a 860 million dollars out of the healthcare system in the city.

Obviously, we did not want to do that.

Uh if you jump to slide eight, I'm gonna talk a very little bit about how our budget um uh what was constructed.

Um as you see on that table, um the proposed budget for DHCF is roughly 5.3 billion dollars in total funds, that's federal and local.

Um now this is 169 million dollars less than the approved budget for fiscal year 26, but uh our actuary and April tell me this is a function of the fact that we have a projected lower spending rate, uh lower spending for the average commercial rate, which is a funding mechanism for the hospitals that we'll talk a little bit more about later.

Um, and also the budget accounts for um the lower Medicaid enrollments for people who are now in Healthy DC, about 15,000 former Medicaid beneficiaries.

And also there are 2,000 former Medicaid beneficiaries over the eligibility level who also now are on the exchange.

Those factors um help push the um total spending for Medicaid uh for 20 proposed for 27 below what we were spending in 26.

But if you look at local funds, uh there's uh a a 64 million dollar increase.

Uh three factors do drive that.

Uh we are maintaining coverage levels as we talked about earlier, uh, and you say, well, if you're maintaining the coverage levels, why does that drive up costs?

Well, we're seeing a shift in the uh health care costs of our population.

They are uh getting older, they have more chronic disease, and so when you maintain eligibility, their population becomes on a unit basis more expensive uh to serve.

Um we've added uh dental envision benefits as we discussed earlier.

Uh and um the federal government uh for some reason uh decided to lower its contribution to DCAS, and we had to backfill that.

Those things uh drove a hundred uh a sixty-four million dollar increase, which was somewhat um, as you will see on the next page.

If you go to the next page, we talk about what the uh the local changes.

Um if you if you look at um, first if you look at the total change in our budget, the there's a negative two hundred and five million dollar uh uh change again due to the lower ACR payments.

Uh but locally we have a plus thirty-six million dollar uh uh increase because of the higher cost associated with Medicaid and Alliance, and on the Medicaid side, the when we sort of try to isolate what their cost is, it's about sixty-five million.

And again, that's because we think we're serving a population that's a bit sicker.

Fortunately, Alliance with uh um reduce some of their pressure by offsetting uh the uh increases in Medicaid on from the on the local side, uh, frankly, because of the moratorium where people cannot get back in uh if they leave.

And one of the things that you know, one of the phenomena that we'll try to um uh combat um is the lower renewal rate.

Uh I get emails not every day, but I get emails from uh providers who are asking about uh reinstating a beneficiary, and I might say, Well, are they over the income level?

And they said no.

I said, Well, why do we need to reinstate them?

They should already be in.

And it turns out that they won't, they hadn't renewed in time.

Now, if they identify that problem within the, I think it's the 90-day period, we don't, we don't have an issue.

We can get them on.

But if they come after the period of their re-enrollment and period period expires, then it becomes more challenging, and I would be violating, I guess, local regulations and law if I said, yeah, you're outside of your re your renewal window, but you will get you back in.

Um we did that a little bit early in the process.

I forgot the reason why the how we justify the Eugene can explain it, but we helped a couple of beneficiaries who were in that spot, but that option is not available to us now.

So that those two things, the moratorium and the failure to timely renew is uh creating savings that is offsetting the uh pressure we see in the local cost created for Medicaid.

I'm not gonna spend a lot of time on the administrative uh budget except to say it's on the next page on slide 10, except to say that um you know um the biggest uh challenge we not challenge, but we had to fund the uh the uh the loss of uh the gap created by the federal government's refusal to fully fund uh DCAS.

Uh and also we have grants to healthy DC of over 10 million dollars for the dental envision benefit.

That those things are driving the change you see in the or the increase you see in the uh uh our administrative cost.

I would now quickly take you to uh slide 12, which lists um not that one.

Maybe my yeah, that looks like the one.

No, uh that's 13.

There you go.

Yeah.

I asked Melanie to fix the numbers last night, but apparently she did not listen to me.

Are y'all numbers incorrect?

Um so the um our budget, despite the tough budget times, um our budget contains multiple um key investments.

Um we mentioned the um mayor's effort to sustain eligibility for Medicaid and Alliance.

She did so, and that's costing on a local value uh roughly 125 million dollars by sustaining uh those eligibility levels.

Uh we extended the benefits for alliance and uh that's 4 million, and we extend the benefits in the same way for those uh um in the healthy DC plans, 5.7 million.

Um there is a reserve from uh that we uh that's in our budget for uh Cedar Hill, the contract requires that they that reserve fund be funded up to 25 million dollars, and when that happens, we can stop putting money in.

Uh there are rules about whether and how they can draw that money out, and if they don't use all of it by a certain date, then the balance reverts to the district.

My hope is that Cedar Hill will begin to um uh at least break even or short profit um and uh this reserve fund will uh will be returned to the city.

We know they're gonna use the first five million because of the substantial losses they had.

And with the DCAS support is mentioned as well as an as an investment.

In terms of reductions, I think um, you know, with the exception of the um the, you know, the the decision that we had to make to uh eliminate payments for teaching hospitals on the uh uh GME side, I mean the DME side, um, which was 14.9 million.

The other reductions are pretty um minimal.

We did save 1.6 by expanding the preferred drug list, and uh Melissa and her folks can explain how that works uh and how we uh recoup 1.6 by basically covering managed care and fee for service with a streamlined preferred drug list program.

We also have uh prospectively reduce the payments or we'll prospective reduce the payments for managed care um for our three managed care programs uh by about five million dollars, forcing them to meet the um efficiencies that we expect them to meet with respect to hospital readmissions within 30 days, uh limited use of the emergency room for uh uh lower curity problems, and uh the um the third one obviously skips me.

Oh, the um avoidable hospital admissions.

Um I will say that I got a um a notice from my insurance company to tell me how to avoid hospitals.

Uh uh, so I I I'm wondering if the uh if if medicaid beneficiaries who who are frequently using hospitals get those same kind of notices from our health plans they should although in my case the host the um my insurance company was off off base I didn't use the hospital inappropriately um and we we had a small reduction in uh payments for empty beds um and in a and specifically we would we reduce the number of bed hold days in ICFs um which we pay for uh it is a unique concept that has always um since I first became acquainted with Medicaid that has always befuddled me but my experts tell me that uh it is something that we need to do but in this case we had to um we saved 134 uh thousand dollars uh I now want to go to slide uh 15 and I'm not gonna spend a lot of time on it other than to say and if you have questions we can certainly dive into this in more detail that we have uh we've made significant progress in um getting the waiver approved for uh the state directed payments we've made uh several payments uh for uh fiscal year 25 totaling over 442 million dollars um cms has approved 485 and we anticipate making one final payment uh in the closeout of uh fiscal year 25 um we'll make that payment in May or June of 26 we have submitted all of the um documents to renew it for 26 uh we responded timely uh thanks to Eugene uh with multiple questions from CMS and in 26 hospitals will do very well they'll get uh uh not a net number but they're at the state director payment will increase by 658 million dollars 27 is going to go down because of some technical changes that uh the federal government uh made to uh the provider tax and so they will they will revert to um uh a level close to 25 and then we are required to start reducing uh those payments by 10 percent each year until we hit uh what is the uh um uh 100 percent of Medicare this will be if if this is if this is not uh changed at the federal level hospitals will lose a lot of money uh because they we won't be able to pay them at the um current levels they're being repaid uh paid because of the provider tax but you know it may well be that this is a policy like the dispro disproportionate share program which I think they've been uh threatening to eliminate that for how long since 21st since 2014 and we still have the program so maybe um they will rethink uh the problems that will be created financially for hospitals if they stop these um state directed payments uh it is a it will create a significant problem for not just hospitals in dist in DC but all around the country especially in in in rural areas uh so maybe they will rethink that um when the political uh heat uh sort of fades um if you go to the next slide uh I know you're probably gonna get a lot of calls if you haven't um about our uh cut to DME uh this slide shows you uh what the net inpatient and outpatient revenue from DHCF is to acute care hospitals uh in fiscal year 25, 26 and 27 uh the uh total value of our payments uh payments that are that are are being made and ones that are projected are at the bottom of each um each of the uh bar bar graphs you see uh and if you go to the far right you will see that we have proposed removing 48 million dollars in total from the uh fiscal year 27 payment and if you go to the next slide you will see which hospitals are hit the hardest and I think your staff requested and received sort of the history of uh DME payments.

And if you look at that, most uh hospitals' payments are level across the four-year, five year period that you, the five-year look back that you requested, the exception being uh uh Washington Hospital Center, they got a a pretty significant jump uh I think in the third or fourth year of the five-year period that we looked at.

And consequently, they're taking a big hit.

I tell people all the time, I'm a big fan of hospitals.

I think people dismiss unfairly the um their importance to a community and the work that they do to keep people healthy or to bring people back to health.

And I'm I so I'm concerned for about all of our hospitals, but when I look at the dynamics that are going on at Washington Hospital Center, it makes me a little nervous that if we can't um find a way forward to help them, you know, they they are sort of the anchor for the whole system in terms of volume with a close with GW uh being uh close second, and of course children's has a niche population that and that make them very important as well.

So you don't the last thing you want is the hospital or hospitals where everybody goes uh to be stressed to a point where it affects the delivery of service, and I think that's something that we're gonna have to pay closer attention to in the very near future.

Um, but you can't spend money you don't have, and so when we got to the end of the budget process, you know, we were looking at do we not fund uh childless adults and save 100 million dollars, but in the process take a billion dollars out of the health care system, or do we do something like take money from GME, and then you only have to find 50 more million dollars to balance your budget.

We chose the latter obviously because we th we we correctly believe that if we had not funded funded childless adults, we could have crippled the health care system in this city because you take a billion dollars out of any system, it's gonna have a tremendous effect.

Uh one of the uh graphs that we always show whenever we have the chance, because it's it's this graph on slide 19.

Um, it it shows you the reliance uh in this city on Medicaid uh and to a certain degree alliance.

Um, 41% of the people in this city um rely on DHCL for health care coverage.

There have been times in the past, certainly around the pandemic when that number was 50 percent.

It's half of the city.

Now it's 41%.

So, like I tell people all the time, if you could land if you could randomly line up every resident in this city and walked and touched them, you know, four of every 10 people you touch would be on uh Medicaid or lines.

That's a lot uh for a system to uh to bear.

Um we track enrollment levels closely because of their budget implications, obviously.

And as you can see on slide 20, um, after um, you know, some uh declines during the time um before the pandemic, then a rapid increase during the pandemic and just shortly after, and then a slight decline.

We believe the numbers are uh are beginning to uh uh are beginning to increase again for Medicaid, and that will have cost implications.

Um slide 21 I think is an important slide because it shows you uh that when you look at the three major health plans, uh they have a high percentage of members with chronic conditions, and we give them fifty-two million dollars annually to provide case management services.

Um probably only one health plan does it well.

I don't think any of them are compliant with their contract that says 3% of the population, but two who are not compliant are spending way over what they are required to expend on medical expenses.

One plan that's not compliant is spending substantially under what uh is required uh by both uh the federal government and DHCF.

Now, what does this mean when you say they are struggling with case management?

If you go to the next slide, you know, we are the health care the health plans uh by our estimate of our actuary's estimate um could um is paying about fifty-seven million dollars a year more than they have to um and if if they have better case better uh uh care management.

Uh if you look at the last group of bars, the total, um the 57 million, there's 57 million for um that that includes uh avoidable hospital admissions, um hospital readmissions, um, and the uh uh lower curity use of uh the ER.

We think these are things that the health plan should make a more concerted effort uh to um make sure that the city is not spending money that uh we don't we shouldn't have to spend if this if this care was better managed.

But I will be frank.

The uh drift and managed care is toward public health plans, and I have seen a rather disturbing emphasis on let's make money.

Let's see how we can make money.

To the point that they've you know, some have even asked um, can they basically not hire uh can they cut their care management staff?

You're not even meeting the threshold, and you want to cut the staff, and it's all because you want to feed the bottom line.

I think managed care, the more and more we uh see publicly um publicly owned health plans, the more difficult it's gonna be to uh get them to focus on things that cost a lot of money and hit their bottom line, but it's good for the city and good for the beneficiaries.

Um if you look at it on a percentage basis, uh the next slide shows you that to avoid uh this avoidable spending amounts to about 15 percent of managed care spending on emergency room and inpatient care.

So 15% of what we spend on emergency room and inpatient care is probably avoidable if we had more aggressive um care management from our health plans.

Um, so I think, you know, and I'll close by saying this: I think the time has come to rethink how Medicaid uh case management and care coordination is delivered.

Uh we are now seeing enrollment growth among um higher cost older adults and beneficiaries, many with chronic diseases, and this will absolutely test the Medicaid program's ability to deliver access to quality care in a model of uh effective case management.

Um we are pursuing this through our caring model with a heavy reliance on managed care and more recently the PACE program, which frankly are neither have produced the results that we completely anticipated.

Um I think there's scant evidence to support the view that health plans are successfully managing the care for a significant number of beneficiaries.

And I don't mean to imply that it is this is easy, it is very difficult because it's an opt-in uh process.

You have to get the beneficiaries to agree to be be managed.

But as I tell the health plans, if it were easy, we would do it ourselves and save a say fifty-two million dollars a year.

Um so the the lack of efficacy that we see with this approach is frustrating for the amount.

We're spending 52 million a year, and um I think um one of the possible solutions is to try to move case management and care management on the ground with the pe with the providers who are delivering the care.

Um so I've asked my team and representatives from the FQHCs to uh sort of reimagine how we might better organize uh case and uh care and case management for Medicaid, possibly moving this function and the funding from the MCOs and locating those activities within the federal requalified health centers.

Uh as we think through these issues, uh my team and I will be sure to keep you and your staff apprised of any developments in our thinking.

And that um, Madam Chair ends uh my uh testimony for this morning.

Very quick, as you see.

You know, uh Director Turnage, because I know this is your last go after such a distinguished career.

I feel like you wanted to set a record here um and so i think you did.

What you desired okay um all right let's get into some of these questions okay so we've talked about the medicate management information system before MMIS um as I understand it an update is required um or an update slash upgrade is required by the centers for medicated and medical services to happen every five years um last I spoke to your staff CMS had not yet approved our upgrade what's the status currently I think is Don here um what what we typically do and Melissa can pick it up we we in once we get to a point where um we invite CMS in and they test the system and then we show them the results of our efforts and then they decide whether or not they're gonna approve it I don't know if we reach that point yet sure no I think we typically have a 12 to 18 month period for what's called certification and that's that final approval but that isn't the first touch point we have uh with CMS with the implementation of an MMIS like they were I think I can't remember if it was virtual on site but in February um where our team along with our vendor gain well presented all the facets of the system to CMS and got the initial go ahead to go live March 2nd.

So it's an ongoing process and we can update you if you'd like as we go along okay um the provider the provider data management system which assists with enrollment and remote re enrollment of Medicaid providers is one module of MMIS.

Director as you recall we held a hearing in March around um centralizing Medicaid credentialing within healthcare finance is a way to streamline it so that providers don't have to go to each of the MCOs and the delays that are associated with that.

Now I understand that enrollment and credentialing are two different processes but how could potentially healthcare finance use this opportunity for recertification to expand the scope of the provider data management system to give it authority to centralize credentialing as well.

Sure well initially we would need to alter the request for proposal to be inclusive of uh credentialing activities um in addition and above to the typical enrollment expectations and in order to do that we would also have to have the appropriate funding to support that okay but no one has told us how much it costs yet I know we we looked at initial estimates um what I do know it was a it was a an ad that I think was a few million dollars total um but we can look back and um see what the latest update is on that and what we did initially was talk to our current vendor um and a couple other states I believe to talk through that um and then we also had some work done by our actuary to see if any of those costs would be um I was hoping they could they could be wholly offset by reducing the administrative cost of the managed care plans um currently expend on credentially it's not a one for one so it would still be a cost um out of the district's pocket if we were to assume centralized credentialing but we can follow up with that okay um you noted in your testimony director that healthcare finance transferred five million for improvements or at Cedar Hill Medical Center I don't say improvements but you transferred it to the fund as agreed to by the operating agreement um are there specific terms to it um meaning it is the hospital required to use the funding for something specific no it is tied to their financial performance uh is the so per the the uh it was put in in recognition of the fact when you start a new hospital it is almost accepted that first two or three years you're gonna lose money.

Okay.

The only question is how much.

And so we put in it as a buffer.

In any year that they don't um break even, then they can draw on the fund for the amount that's in the fund or five million dollars, whichever is is it greater or less, whichever is greater.

Okay.

Um how long?

I think it oh, I think I remember this.

I think it's 10 years.

10 years, I don't know.

Okay.

Yeah.

Um after our last hearing on Cedar Hill, hearing round table.

Um, there's a report that is due.

There was supposed to be a meeting that was had.

Um and then the public is waiting for that report to become public.

My understanding it won't become public until after the meeting is had.

So when is the meeting scheduled for and when can we expect to see the report?

The meeting is on the uh first.

Let me say that uh UHS has submitted the report.

Okay.

Um I'm partly the reason that uh it has not become public yet because I've been out, and um the um I did see on the mayor's calendar that there's a meeting scheduled with UHS as required by the operating agreement.

I think it's in June.

So I would imagine that the report would be public um shortly thereafter.

Okay.

All right.

Respectfully, I'm gonna ask that the meeting.

Even if the meeting doesn't happen in June, I know the mayor's schedule can get sort of sideways, et cetera.

But I think there was expectation that we would have had this report in April.

Um so now the idea that it won't get released to the public until June, although from UHS's standpoint, they've done everything that they're supposed to do.

I think I have an upcoming meeting with the interim CEO, and I'm not sure what we're gonna be discussing, because I guess we will be discussing a report I haven't seen.

Unclear, but the point still stands, um, if you guys can try.

So your your request is that the report be released sooner.

Is this what I think is what I'm hearing, correct?

I'm sorry.

So your request is that the report be released sooner.

Yeah, well, if the for whatever reason the meeting with UHS gets pulled down to August, please don't wait until August to release the report.

That's my you know what I'm saying?

Like the meetings can change, but um this is something that we have been anticipating for a while in terms of our oversight work.

Okay.

Um I want to talk about direct medical education.

Um, you sort of explained some of the rationale for eliminating it, which is simply budgetary pieces, but what conversations, if any, have your staff or you had with our teaching hospitals about this, who's um considering it's May and the end of a school year.

Like their budgets are already set for next school year or the next residency cycle, which would have anticipated this funding.

Yeah, well, you know, there's a limit to how much we can share with any um any provider prior to the mayor's uh submission effort budget, so there was not a lot of discussion with them prior to that.

Um, once we announced we had a meeting with the hospital association two weeks ago, whenever it was three weeks ago, uh, where we presented this information uh, and of course, some expressed alarm.

Um we are certainly willing to have any conversations that they um they would uh that they would like to have uh on the impact, but at the end of the day, and unless we have more money, there's not much we can do.

Um but again, I am um sort of on a larger issue.

I I am having discussions with, you know, at least one hospital about some of their challenges, but it wasn't directly tied to um the uh DME cut, although that's a part of it.

So yeah, I mean the the hospitals are real really concerned.

Um, but we you know we can't take on a uh item um that we don't have the dollars to pay for.

Okay, and we heard from testimony from multiple witnesses concerned about what this will mean for residents' salaries and for hospitals across the district.

Um, you know, you spoke very fondly of hospitals, but our teaching hospitals are our residents are I would say the lifeline of our hospital system here in the district, and they already get paid below poverty wages, in my opinion, and sort of the name of well, you're getting an education out of it, um, even though they're working, you know, 13, 14 hour shifts in some cases.

I feel like this I know that um trade-offs had to have been made, but it also in a situation where we already have challenges with the health care workforce, this is like another hit.

Well, it would have been a bigger hit if we had cut um Charles Adults, because they would have lost the hospital system would have lost, or the health care system would have lost a billion dollars.

And I'm not suggesting that hospitals are flush, but the state-directed payments do help considerably.

Um, you know, hopefully, this will be a temporary uh challenge that can be revisited uh if you know revenues return in future years.

Um so I my sort of view it as a uh a year by year issue that we can certainly uh or somebody can certainly take up uh when the uh revenue picture is more um maybe changes for the positive, hopefully.

But you know, that's that's a big hope now in the district because of the uh cost structure for the city and and the revenue patterns over time.

Well, I was glad that in your testimony you uh sort of name, like I'm concerned about Howard, because this on top of Dish that is like a double whammy.

Yeah, how would it owes us how much 30 million?

Howard owe us about 30 million dollars for overpayment on dish.

So we didn't cut their dish, we paid them more than they could justify.

So now they have to pay us back 30 million.

Now we can if the mayor decides she wants to forgive the local share of that, she can do it, but that money, their overpayments have to be first redistributed to other hospitals who did not get hit their dish ceiling.

Right, and then if anything's left, the mayor can say, you know, okay, uh Howard you don't have to worry about paying us back the local, but if if somebody doesn't pay back the federal, then they will get it from the district, and that's a challenge.

Um so yeah, that I I worry about Howard as well, uh, for uh a number of reasons, not the least of which is their the money they owe us in Dish.

How did we get to a point of overpaying by 30 million?

Well, Darren is our dish expert, he does a tremendous job.

Uh, he can explain the process to you, but in a in essence, they fill out a survey to tell us how much we owe them and we pay them, and then there's a reconciliation on the back end.

But Darren can give you the more uh specific details.

Like a million or two, okay, 30.

That's a lot.

Yes, and I don't know that I can speak to the details of that right here, right now, but I can certainly follow up.

But what Director Turner said is accurate.

We send essentially surveys to the hospitals, they complete based on you know their their best information.

We use that information we essentially rely on their attestations that the information is accurate, and that's for all the hospitals, and that's the basis of our allocation of dish funds, and then as federally required, we come behind three years later.

Um, we we have a contract with an audit firm.

The audit firm audits all of the recipient, all the hospitals who receive dish, um, looking, you know, at their allowed cost versus you know the payments, and then they do the the calculations, so that's where it landed for Howard for fiscal year 22.

Okay.

Um I can follow up with you if you want to do that.

Let's unpack that at a uh on another on another day.

Okay.

Um, I want to ask about um you mentioning your testimony a more streamlined preferred drug list for Medicaid MCOs and uh fee for service, which should cap or capture, excuse me, around 1.6 million dollars in local savings.

Will these drug lists be made publicly available?

Or like how do you all communicate this info to both patients and providers?

Sure.

Um I'll give the initial and then if Dr.

LeBird wants to add anything on.

But yeah, our our preferred drug lists it will be made available.

What we're doing is creating a single preferred drug list.

Currently, we have one for the fee for service program, and each of our managed care plans has their own preferred drug list.

So we have six across the board, yes.

Yes, I see.

And so the idea of going to a single PDL, my like personal interest in this is last time we did a significant managed care transition.

One of the biggest complaints we hear from residents is moving when they must move plans.

They're sometimes their uh prescriptions that they're accustomed to change based on uh the new plans PDL.

So going to a single PDL allows a uniform uh preferred drug list across our program.

Um we believe it will also help providers in terms of they'll know what's available to Medicaid beneficiaries, it helps our residents knowing what's available to them in the program, and as uh the deputy mayor suggested or presented in the testimony does um produce some savings to the district.

Okay, um I was pleased to see the 5.7 million dollar increase for the dental and health um dental envision coverage for the healthy DC plan and $3.9 million for dental envision for the alliance program.

Um we've discussed this before, but hopefully a lot more people will choose to uh continue to uh invest in part of their oral health and their their eye health as part of this.

Um my understanding from Health Benefit Exchange Authority is that this benefit can't start until the start of plan year 2027, so that would be in January.

Yeah, I baguely recall that.

Be correct, yes.

Um, so I guess two questions that I have.

Um, the 5.7 and the 3.9 million, is that enough budget to carry through the 12 months of 2027?

Because this is the weird part, right?

Like we we budget on the fiscal year, but this would need to cover across the plan year, which is that side.

Yeah, I think it is not in one April, you know.

So, excuse me, April Grady, interim senior deputy director of finance, the one with the big feet, uh so uh the alliance estimate for dental envision is for 12 months of the fiscal year, so beginning in the last quarter of calendar 26, going through the third quarter of calendar 26 for HBX.

We'll get back to you, but my understanding is that is a fiscal year 2027 estimate.

So that would be the first nine months of calendar year 2027, and then the financial plan would cover the last quarter of the calendar year for HBX.

So I just want to make sure that we don't have any gaps because of that, but also I'm gonna say for the public who might be thinking, oh, I can get my dental envision coverage starting October one.

Unfortunately, it won't start until January one.

All right.

Um, speaking of alliance, the FY26 supplemental swept the 21 million in the contingency list um funding um to restore benefits uh for enrolled alliance beneficiaries as well as a 25 million dollar savings in terms of reduced enrollment.

So, the fact that they were able to find 25 million dollars in savings in fiscal year 26 because of reduced enrollment suggests that we've seen a steep decline in the alliance numbers.

Um how many people are currently enrolled?

I'm pulling that up right now.

Uh but you are correct that we have seen um some pretty substantial reductions in um enrollment.

Part of that is because we did lower the eligibility level for a adults from 215 to 138.

So part of the sort of big drop that we've seen just over the past year is attributable to that eligibility reduction.

Okay.

Um for the people who remain for the adults below 138% of poverty and children up to 324 because we're still consistent with the Medicaid uh program on children.

As Deputy Mayor mentioned earlier, we are seeing lower renewal rates than we have historically.

So that is a contributor to any enrollment declines that we've seen in addition to the um eligibility change.

And then in addition, the moratorium also has an impact because to the extent the adult enrollment moratorium has an impact because to the extent that someone falls off because they don't renew, we don't replace them, right?

So this is sort of a two-fold contributor to any reductions in enrollment that we're seeing.

So I just need to flip to my correct tab for my enrollment.

Okay, while you're looking for that April, um we've requested a variety of different um cost estimates that we haven't received yet.

So how much it would cost to remove the age moratorium at the current income eligibility at 138, how much it would cost to take the age moratorium back to 26, how much would it cost to restore the program back to 215?

Um XYZ XYZ.

I I marked this budget up next Wednesday, and I don't have budget estimates for some of the pretty big things.

I can't even tell my colleagues how much it would cost.

When will CMS any you will get that today?

Today.

Yes, all of those.

Okay.

I would um I haven't seen the estimates yet, and uh certainly don't question what Darren and his team do, but I would imagine that is a very difficult estimate to produce for a number of reasons.

Particularly if he was talking to saying what would it do, what would it cost when you take it back up to 215?

Um we have to sort of understand how many people would come back to the program if there's no moratorium.

You also have to understand if you take it up to 215 and don't adjust Medicaid, then there are a lot of people who are in the exchange who will push out of Medicaid and into the exchange, you know, in a very um, you know, careful and systematic way.

They'll probably come back to the Alliance because there's no cost uh on the alliance, whereas on the exchange they have cost sharing.

So it is a complicated estimate to generate.

Um if you miss uh the consequences could be uh pretty catastrophic from a budget standpoint.

Okay.

I look forward to receiving the estimates today.

Um, last year, healthcare finance was able to absorb the cost of annual recertifications instead of recertifying every six months, um, as well as allowing um for recertifications not to happen in person.

Can you confirm on the record that the budget that has been proposed is for annual recertifications, not every six months?

That's correct.

Okay.

And will these recertifications be required to be completed in person?

No.

We have not proposed changes to the alliance recertification process.

I will note just um on the Medicaid side, we will go to six-month recertifications for childless adults starting January 1st, 2027, as required through the one thing beautiful bill that will those be in person.

Or they don't specify okay, all right.

Um it's been about seven months since we um switched the alliance program from uh MCO over to a fee for service model.

Um your staff uh sent in pre-hearing responses that um we've been trying to ask questions around like trends utilization um thus far.

And um there was one area where claims are lower that now than they were before the alliance program changes, and that was around pharmacy.

Uh I'm curious, are you all concerned about the reduced pharmacy utilization?

Or would it be too much to just sort of read into one data point?

I would say we're certainly looking at it to make sure that it reflects appropriate utilization that we expect, and I'd say a few things.

Um, one is that we get detailed reporting from Prime, our pharmacy benefit manager about the types of drugs and um are tracking that very closely.

The other thing is we've looked at the pharmacies where the prescriptions are being filled, and I believe you mentioned um in the public uh testimony hearing that we had in the past a number of fills that were happening out of the district.

So in Maryland and Virginia, um, those have been substantially reduced, is what we are seeing in the latest information.

Um so we are gonna dig further into this, but um at least part of the reduction may be due to uh folks filling uh largely here in the district.

Last thing I'll say is it's not um unexpected or inappropriate for someone to fill outside of the district, for example, if they have a job across the state line, um, but that is something that um we're going to be looking a little more closely at.

Okay.

Um Healthcare Finance anticipates spending about 36 million dollars more in local funds this year because the populations for Medicaid Alliance have shifted, as you sort of mentioned in your testimony, older.

They also have more chronic diseases than the population a few years ago.

Um the primary care association and the connected care network testify that they have data that shows that alliance beneficiaries who receive care from FQHCs exhibit lower emergency room use and inpatient utilization and have lower overall um disease prevalence.

Have you guys looked at this data?

Um, and I guess whether the argument that's being presented by the DC PCA.

We had a very productive and long meeting with them.

I think their study, I mean, it's a good study.

I think it has some methodological challenges that they can't overcome.

But uh I wouldn't say that the uh results are completely off because of those challenges, and basically the challenge is the population they have is lower risk than the group that they compare them to.

So they try to adjust for that statistically, which you can do to a certain extent, but not completely.

And so you could be overestimating the um the impact for your program group because they are they come in with a lower risk, and so they're less likely to go to the emergency room and hospital.

And so if you're comparing them to people who are more likely to go, you really have to make a a sound adjustment for that difference.

They made a good effort at it, and it's very well done study, and I think it has some merit, and it's something that uh one of the reasons frankly that we are you know thinking internally about uh moving case management out of managed care and into the FQHCs.

Okay, you know, it's interesting in your testimony in the slides you presented.

Those last few slides where you were sort of comparing the MCOs on various trends, I think it was around readmission rates, unnecessary emergency hospitalization visits, and I think you noted that like 15% of our spend is on emergency room visits.

Um, and I would just note that it kind of goes back to um something that I uh wrote you and UHS separately around, which was this plan to open a new for freestanding emergency department and ward seven.

If we are spending all of this money on emergency rooms now, opening another emergency room and an area where they desperately need urgent care, is only gonna cost the district more money on the back end, I think, from a Medicaid standpoint.

Well, a slight correction, the uh 15% represents the avoidable spend on emergency rooms and inpatient care.

So it's not all emergency room, but emerging room is a key component to your point.

Um I think the the uh what UHS would say is it's not either oral with this freestanding emergency room that they will have a triage system with sort of an urgent care system where you basically come in and they they evaluate you, and if you are if this is an urgent care need, they will treat it as such, and you won't get to the emergency room.

So it is a more um expansive project than just an urgent care facility.

And hopefully, if they do it correctly, um they will they could actually divert people from the emergency room um with the upfront evaluation of whether or not they even need to be there.

Hopefully.

Let's see.

You you won't be here for that part.

You should run it.

You're running me out of here pretty quick.

I'm not, but I also know that there uh I think we just approved the land disposition for Fletcher Johnson like two seconds ago.

So you know, I don't I don't I don't confident believe, and maybe I'm wrong that anybody's breaking ground on any freestanding emergency department this calendar year.

No, it won't be this calendar year.

All right then, yeah, it won't be discounting.

Unless you are saying you're staying longer.

I don't know.

That's out of my control, obviously.

All right.

Um several witnesses testified this year and last year asking to delegate authority for recertifications to FQHCs.

Um what's the agency's position on delegated authority?

So recertification to the FQHCs.

Yeah, I don't think delegated, it is allowing the presumptive eligibility, I believe is the request, right?

Yes, this pro um has been the request is on the presumptive eligibility side.

Um I don't think it's something that um I don't like that.

Go ahead, I'm sorry.

Okay.

I was like, it's on.

I don't think you like what I'm gonna say.

Um I don't think we have like a philosophical uh uh opposition to it.

It has mostly been um the ability and the capacity to support the FQs and others and actually being able to effectuate it for us.

It does mean uh state plan amendment, things like that, making sure that there's the the training for the presumptive eligibility and all the systems changes as well, um, etc.

So it's it's more process than anything.

Okay.

Um there was a story that was shared about Alliance beneficiary who um is in the hospital.

Um they were treated, they now no longer need that acute level of care, but um uh they can't be discharged yet.

Um partly because the appropriate setting would be either a skilled nursing facility or um having home health care to have an aid to help um with those works.

Um and those are two services that Alliance no longer covers costs for um considering how health care finance pays for hospital inpatient claims and other outpatient care, what conversations are happening to ensure that beneficiaries are receiving the highest value care at the lowest cost possible for the district.

You turned your mic off.

Relative to that circumstance, we always try to on a case-by-case basis, um, resolve it in a way that uh eliminates the um the inpatient care, the unneeded inpatient care.

But you know, after a while the cost falls on the hospital because they can't bill.

If the person is in the in an acute care bed but they're not getting services, then the hospital can't bill anybody.

Um so we want to help the hospitals by getting people out of those beds.

Um because they also hurting throughput, get them out of those beds, uh eliminate the losses for the hospitals and move them into an appropriate level of care.

It is a very difficult thing to do.

Um I know Melissa has worked with several cases over the years, um, but systematically we don't there's it's not a lot we can do systematically beyond what we already do.

And when you have the the not the rare patient, but the the patient that falls into that gap where they don't have long-term care, um, for whatever reason, and they don't have a home situation where uh they can be returned to a home and receive care.

Then we it's a it's a struggle.

We sort of put our creative minds together and do the best that we can.

Uh but fortunately, I don't know, Melissa.

How many of those cases have you dealt with recently?

Um I think probably six or fewer.

I'm gonna look to Dr.

LeBird.

Does that sound okay?

Um, because she handles a lot of them, probably about six or so, and they are intensive cases, um, oftentimes without an option for someone to return home, and um, and then this question of whether they have the benefits afforded to them to to support that care as well.

We did, you know, one of the efforts we put forward um through our 1115 waiver was the option to or the proposal to um bring in respite care, um medical respite.

So for exactly those folks who no longer meet that hospital level of care, but they can't be discharged safely home or elsewhere.

That would be one option that has like a bit of a housing component to it that is um unclear.

I'm not expecting that to probably likely to go through with our waiver approval, but there are some medical components that we're still exploring to see if that's an option long term.

But I mean to to the earlier points about the aging population and on the different concerns.

I mean, this is gonna be an ongoing issue, and it's it's the deputy mayor said, and it ties in I think to the earlier discussion of housing, it's an extraordinarily challenging issue.

Yeah.

Um I was thinking, I was like, I know of um one organization that is trying to set up medical respite beds at the E Street um site.

They're not ready to go yet, and even still, I don't think that it's it's supposed to be temporary.

So I don't necessarily think that that's gonna address the needs.

I do think that's one of the concerns.

Like I think it helps you for probably about up to I know when we were talking about up to six months, but then the questions after that six month period.

So are you kicking the can, the problem's kind of down the road?

Um it makes the initial kind of, you know, ensuring that we're utilizing hospital beds for the appropriate use, which is ideal, um, but it doesn't completely ameliorate the issue or make it go away.

Um, Deputy Mayor, you brought this up in your testimony, but um I'm also asking on behalf of um some of the advocates who brought this concern, which is that there are some alliance beneficiaries who um maintain their coverage posts the October one changed, but for some reason did not renew within the 90-day grace period and are now trying to renew their coverage but are being blocked due to the moratorium.

What options, if any, do these individuals have?

Legal options.

I'm sorry?

So legal options, yeah.

Legal.

Nobody, yes, legal.

We're on the record.

Yes, legal options.

Um, you know, it's it's a it's a it's a very hard thing.

I I will tell you when I get those cases, and Eugene and Melissa can attest, I'll push real hard to try to get them back into care.

But we are um once we get past the gray area, um, that we had a large gray area doing the early um execution of the policy.

Once we get past the gray area and it is clear that the person did not renew in time, and that the moratorium has now therefore is therefore in effect.

It's hard to um to give them a benefit or give them access to the benefit.

I mean, I will recall to tell you how um, you know, difficult this can be.

Um we um I recall a case where we were dealing with uh a woman who had uh um cancer, and she was not eligible.

Um this wasn't a line, it was a Medicaid, and so I went all the way to the attorney general to try to get her uh no, she needed a lung transplant.

And she even got we even got her to the hospital and they said her Medicaid wasn't wasn't active and she was no longer eligible.

So I went to the AG and they sent back a rule and they said you cannot uh specify benefit for a single person or individual case that is outside of the uh the policy outside of the statute and the and regulation.

So, you know, we look hard, we don't give up, but it becomes more difficult.

So I I um I'd I go immediately to Eugene and listen to how can we help this person and doctor the bird?

Sometimes we find a way, and sometimes it's very difficult to find a way.

Um, not that this is on a list or has been an ask, but how much would it cost to extend the grace period beyond 90 days?

I have to leave I have to leave that one from Darren.

I mean, this is a new one.

I know I haven't asked this question before.

We have not looked at that question, so we would have to do some research and get back to you.

Okay.

And I will say uh we had this conversation last week with Mila Kaufman, too, right?

A 90 degrees period is pretty standard.

Um this is when my time for the PSA for any of you 2300 people who have not responded to the healthy DC emails.

Please submit your recertification documents because you are at the edge of your 90 day grace period and will lose your health care.

Um policies are policies, right?

And this is the part that is really difficult.

Um people desire and slash want the government to continue to be this sort of very nimble, non-one size fits all, but a policy is a policy and a statute is a statute.

Yeah.

And Eugene can remember how we were able to justify it when we did it early on.

You want to come up and you remember that?

No, I mean that's okay.

Okay.

That's fine.

Yeah.

I was just gonna say amplify our gray areas from before.

Yeah, I believe early on we were within the grace period for everybody, so during that transition period, we were mostly able to get folks in.

Um, so I think that was the largest reason um how we were able to extend the coverage, okay.

Um, with the changes in eligibility to emergency Medicaid, as well as the federal health care changes um limiting access to affordable coverage.

We're definitely gonna see a rise in uncompensated care that's probably going to arise.

Um how does this budget if at all um set up a cushion for that that might arise for hospitals?

It does not.

Um, but I'll and I'll let April talk about the emergency care um the emergency medicaid calculus.

Uh you know, I the the um the benefit there is dish.

Um but um hospitals have to first of all be a has to be a dish hospital, and the hospitals that this will fall on typically they aren't dish hospitals.

Uh so that would require federal change to what is a dish hospital.

I think it's you know, I've often not told Kim Salmon this semester.

I said, I I don't to me it's unfair that Washington Hospital Center is not a dish hospital because they serve such a large number of Medicaid beneficiaries.

Now it's a smaller portion of their total book of business, but in terms of the impact in this city, it is huge.

And we're giving money, we're not even using all of our dish money, because all the hospitals don't have the amount of uncompensated care to draw down, so we don't use it.

And meanwhile, you have a hospital that is eating a large loss on on um uh the uninsured, and they can't access dish.

So that it's a policy change that has to occur.

But in this climate, I don't know that it will.

The one thing I would highlight in this budget where it supports um kind of limiting uncompensated care as much as possible, is the continued support for the eligibility levels across Medicaid and Alliance at the current 138.

We've talked a lot about today, we've talked today a lot about, you know, the uh if we had cut childless adults um out of the Medicaid program that also would have eliminated emergency Medicaid coverage for anyone who would fall into childless adult category, non-US citizen.

So, you know, it is maintaining the status quo, and there are some, you know, a couple difficult uh decisions that were made um in order to achieve the the savings that we needed, but that investment and commitment to the current eligibility levels really is a strong commitment to trying to minimize and compensated care as much as possible.

Okay, the only thing I would like to add on top of that is you had asked about some of the policy options uh that the committee is considering for removing the moratorium or changing different aspects of eligibility.

Um, to the extent that alliance were to um go back to coverage above 138% of poverty, so covering the 139 to 215 that used to be part of the program.

Um, I just want to clarify that there is not emergency Medicaid available for that increment of the population.

So to the extent that they have inpatient emergency costs, that would be at 100% local because we have emergency Medicaid federal funding for the below 138, but that would be full district cost.

You got that.

Okay.

She's feverishly uh um typing over here.

I will say that this is rhetorical, but for the mainly for the public, right?

I understand sort of our desires to have parity amongst the Medicaid and Alliance populations, because that has always been our line.

However, um individuals who are above 138 have a have a new option that is not available to you if you are not eligible for certain reasons.

You know what I'm saying?

Right?

So like I I know we're always trying to match, but I think the circumstances are very different from a Medicaid uh beneficiary and an alliance beneficiary, and I just want to name that.

Yeah, so you have an option if you have Medicaid above 138.

You don't have that option above 138 if you're on alliance.

That is true, but then you would have to have language that prevented those people from coming back to the alliance, because they will come back because it's cheaper.

A healthy DC person choosing to switch to the Alliance program?

Yes, because they don't have any cost sharing in alliance, like you pay for everything, and so they would avoid all cost sharing.

Uh and that means something to somebody at that income level.

So unless you have language that says, I don't know how you would word it, but you would have to specifically limit eligibility to alliance if you are eligible if you are meet the criteria for Medicaid.

Well, I don't know.

Yeah, you'd you know basically what you would have to do is say that we're going above 138, but only if you are an undocumented uh are you only if you're not lawfully present.

If if you're lawfully present, you can't come back to alliance, even though we're taking it up to 250%, and there will be some significant tension around that type of policy.

Or lawfully present considering HR one remove the eligible the eligibility of people who are lawfully present to even be a part of healthy DC.

We got like what 845 of those 845 individuals who are here lawfully present, but because of changes in HR1 are gonna lose their health care in January.

Right.

So it and those people would come back to the lines too then.

So our number would grow.

Well, I mean if she lifted the moratorium, okay.

Um I want to ask really quickly about uh state directed payments.

Have you all had conversations with um the hospital association to determine how for the fiscal year 2025 bucket, how the money will be spent for the various priorities, and just to remind you the topics identified in FY25, um, when we did this language through the BSA, um enhance care coordination, addressing social determinants of health, improving nutrition access, strengthening maternal and child health outcomes, supporting long-term care discharge and transitions and um expanding substance use services and investing in workforce development pipelines.

You know, I think you know, I um a lot of what they do, a lot of them do that as a matter of course, not everything you mentioned, but a lot of those things you mentioned are are done as a matter of course.

Now, I don't know Melissa, I don't know if you had a conversation.

No, we have internal ones set up sometime within the next couple weeks, I believe, and then we'll begin that outreach.

The focus really has been getting on to initially the initial approval by the federal government, which took an extraordinarily long time, and then moving into the second and third rounds um for the 26 and 27 uh requests.

So it's been more focused on that piece and not as much on the other, but that's on our plate for now.

Okay.

I mean, I want to make sure that like there was an agreement here, and um I want to make sure that the investments happen.

So who is is this a health care finance you all monitoring to make sure because you know we get into additional fiscal years, so we're moving into FY27.

People forget, oh wait, there's still some things from FY25, we gotta wrap up.

We can monitor and cajole, but uh I don't think the money comes with strings.

Um they paid the tax, they get the revenue, and then we can try to, and I don't think the effort would be that heavy of a lift because I think they'd want to do a lot of these things anyway.

Sure, but legally they would need to demonstrate that they spent the money in some of these buckets.

No, you don't get to just get the money and then not say what you did with it.

I don't know if there's language, I may it may well be.

I yeah, we it's in the it was in the budget support act in fiscal GH25.

I didn't I didn't know the language mandated that I thought it the language was um sort of guidance, but I I have to go back and look at I haven't looked at it in a while.

Well, if the language is there and it says this is what you must do, then we will certainly have conversations with them, and we can easily monitor you know how they're spending them.

Not easily, but we can monitor how they're spending money.

Hospitals are very complex entities, and their books are, you know, are uh are difficult to decipher, but we could we'll take us also take a look at it.

Okay.

I was just saying when we did this and 25.

I guess, yeah, 25.

It was the understanding that the hospitals were getting some money, the city was getting some money out of it, and then there would be some monies that are directed towards priority areas.

We don't specifically say, and you must do X program, but we did say these areas did need to be hit.

And so that's what I'm saying is like, are we checking to make sure that everybody's holding up their end of the bargain?

You're correct.

My you you've jogged my my memory.

There was um, I remember talking to Jackie about that extensively.

Yes.

Those those things will be easily monitored.

Uh and Jackie will sort of help us because she was this is something she has championed.

Right.

So I thought you were talking about the entire pot of money for uh no no.

Okay.

But like understood.

When we said yes to this, there was like, okay, we're gonna do an enhanced focus on these priority areas, and I want to make sure that we're delivering.

I remember well now.

You're correct.

Okay.

Um, in terms of the changes that HR1 uh, I'm trying to use my words wisely.

The changes that HR1 is requiring, do we have to resubmit something to CMS for 27?

We've submitted you're welcome.

Good morning, good afternoon.

Oh, good afternoon, Eugene.

Eugene Sims, I'm the policy director at the Department of Healthcare Finance.

So we've heard from CMS.

Um they have not been exactly clear about what we need to submit to um as it relates to the lower uh threshold for FY27.

We know we'll need to submit uh uh updated state plan template.

Uh we expect rulemaking from them about how they're gonna uh expect us to implement HR1 changes, I think in the near term, maybe June ish.

Um, but we know we'll have to submit the updated tax demonstration.

We know we have to submit the updated state-directed payment template.

Um, and if there's additional things that don't be required, we have yet to hear those from CMS, but we know they're working on uh federal regulations.

Okay.

All right, thank you.

Okay, okay.

Um, final two areas work requirements and DCAS.

And then we can get out of here and everybody go have a good lunch.

Uh okay.

You all I believe received about 2.5 million from um the feds um to implement changes in terms of the work requirements.

How are you all allocating that funding?

I know you want me to.

We expect that most of that will be within DCAS.

Um, and we are expected to spend that in fiscal 26, so it would be uh separate from any fiscal 27 conversations about funding.

Is the implementation grant funding?

I don't even call it a grant, but um was it only one time?

It is one time.

Yeah, federal government giving everybody all the states a multi million dollar mandate and only give you pennies one time.

All right.

Um is the CMS guidance on implementation finalized yet?

Uh no, the interim final rule is technically due by June 1st to be published.

We do know it's been conveyed to the Office of Management and Budget, which is usually the last step in the clearance process before publication.

Okay.

All right, we talked a little bit about some of these questions earlier, Director.

So just give me a minute.

I'm trying to.

Well, I guess I saw this question.

Do you guys know how many families are overlapped in Medicaid and SNAP?

We do not currently, but we have a data use agreement working through the gears right now to be able to do that analysis.

Okay.

All right.

Um, I I know on the SNAP side that if the requirements were in effect today, I've got over 17,000 residents who would um not be in compliance.

So I would it would be nice to know what that overlap is on um both.

Uh, okay.

So we've heard some feedback from um community partners with a request for certain conditions to fit under the definition of quote unquote medically frail.

Um the medically frail definition for work requirements, is that a local definition or is it something from the feds?

Um the federal government is or has provided guidance rooted in two existing definitions of medical frailty.

Um I think where we have the local flexibility, is when we look at which diagnosis or billing codes fall within those definitions, and that is what we are focused on, and that is what will really kind of um flush out what medical frailty looks like for the district.

Okay, for the states who have gone first, are we gonna be bound by their definitions slash implementation?

That is not expected at this time, but without final guidance, anything is possible.

But no, I'm not expecting that.

Okay.

Okay.

What is likely to happen?

There will be significant variation in how medical frail is defined to a point where CMS two or three years out, we'll come up with a standard definition.

That's what I think we'll have.

I don't know.

No child left behind.

We told every state that every child had to be proficient, and then we allowed every state to define proficient for itself.

Until we decided we actually don't care about children being left behind, and they basically repealed the legislation.

So they have a different incentive.

You have hope.

Well, my hope is that it's not based on uh a goodwill at the federal level, it's based on their incentives.

Um, you know, I can see.

Which are financial in nature.

Yeah, absolutely.

Okay.

Um, DCAS.

That's funny little thing that has cost us three football stadiums over the years.

But it works.

What's that?

It works.

It works.

Works well.

The last time you talked to some of the staff over at Department of Human Services about the uh operational workings of we have a running disagreement about what the problem is.

So I don't talk to them too much.

You guys are the ones who have the contract to build out the system.

They are the ones who have the workers who have to use it every day, but you're gonna have an operational disagreement.

Well, let me remind the history.

We gave this them complete control of the project and the system building when it was started.

They wanted all of these programs, and it's very complex, and it kind of imploded.

And so then the N-City administrator said take it back, DHCF.

And we did, and we got a system out of it now.

I think there are some things that have to be done to make it a little bit easier to use, but uh those things are underway.

Uh-huh.

Okay.

Um, how are we ensuring that there's no duplicative funding to make the changes to DCAS, giving multiple funding streams that are now allotted for the program?

So you have capital enhancements, you have operating enhancements, and now you have federal grants.

I think the the high level response, and I'm getting into stuff that others don't know better about, but we cost allocate everything.

We have a cost allocation plan for the for DCAS.

And so you have based on um uh the number of folks that you're in Medicaid or SNAP or TANF, and it's you know marked out by percentages based on the program, and the cost is allocated appropriately.

So that's that's the really high level way that we track those things.

Okay.

Um director, I talked to your staff about this, but everybody was like, ah, we gotta wait till Wayne comes back to answer the question.

So um, as you know, we have a bill pending in the council for Medicaid buy-in, the Judith Human Bill for Workers with Disabilities Act.

Um, the fiscal impact statement for that calls for a hundred and ninety-nine thousand dollars, um, to do software upgrades for DCAS.

I kind of feel like out of the 90 million dollar proposed budget for DCAS, 199,000 is a rounding error, perhaps.

Um, also given that there has been a balance at the end of every fiscal year for the past seven years in the DCAS line item.

We went back and looked.

Um the total local share over the financial plan is 400,000.

It's 200,000 in FY27.

My question is whether or not healthcare finance can absorb that cost.

Um, we'll if I haven't looked at the data that the way your your folks are.

Um everything you say seems very reasonable.

Um I can certainly talk to my team to see if we can find a way forward with this.

Okay.

Hopefully, somewhere in the 90 million dollar cost allocation line for DCAS.

We could find these kind of conversations cause Darren to swear.

199,000.

199,000.

Darren.

I can feel them tensing up as well as I was speaking.

I'm just saying, let's see.

16 million dollars in uninsport allotments over the course of the past 17, seven years.

25 million dollars.

It's okay.

Local?

No.

Total.

Total.

Yeah.

Not local funds.

Correct.

Right.

Yes.

All of which over 200,000.

Yes, I would point out, however, one cannot match federal funds with federal funds.

So having excess federal funds available doesn't mean those that funding could be used to match other federal funding in order to accomplish the goal.

I told you we're gonna get them started.

I know.

We could share data.

We could share data.

I feel very confident that in the local allotment where there's always DCAS money available, that we could find 200,000 um together.

Okay.

Uh director, is there anything that I have haven't asked that you guys want to share for the record?

So, no, I I won't speak with the team, but I will say there's nothing that you haven't asked that I would like to bring to your attention.

I'm missing a page.

We're not done with questions.

Sorry, I thought we were done.

They're missing two pages.

Uh-oh.

They're on the printer.

Okay.

All right.

Dun dun dun.

Apologies.

Got some maternal health questions.

Okay.

Um, so okay, during public witness testimony, some advocates share concerns that pregnant patients um were being denied access to Medicaid coverage because DHS was asking for proof of pregnancy in the application process.

Um, can you confirm for the record the steps that a pregnant person should take when applying for Medicaid coverage through district direct, what documentation would be needed?

A person does not need to verify their pregnancy, they can say they are pregnant and provide us the expected due date or conception.

No, yep.

Um, and that is sufficient.

We understand that sometimes folks get messaging from a service center that contradicts that.

We have followed up as recently as last Wednesday on that issue because our stakeholders raised it.

It's not the first time it's happened, but it's been several months.

Uh, my understanding is I think for some of the other social services programs may specifically be TANF.

There is a requirement when you're in your second or third trimester.

And so we are working with DHS to make sure that the Medicaid policy is clear and distinct for the case workers, and it's understood that you do not have to show any verification of your pregnancy for Medicaid.

All right, a few long-term care questions, and then we'll be done for real.

Apologies.

All right.

One of the attachments that Healthcare Finance shared with us in the pre-hearing responses noted that the home health rate study was suspended.

Now I understand from your staff that this was because the vendor did not, or I guess you guys felt like the information that you had at that point was sufficient and that you didn't need to move forward because you guys were looking towards a bundled rate.

What's the timeline expected to implement this?

We are in those discussions right now.

It's likely not before 28, not before 28.

Everyone's giving the correct head nod for that.

Um but those um will have a better timeline probably within the next uh month or so.

All right.

Uh we had a resident who reached out to the committee because her disabled son requires care from one of the health care finance contractors.

Um she's been extremely disappointed by the level of responsiveness and care that her son has received.

And I won't say on the record what the company name is.

I can share this with you guys after the fact.

But the contract does appear to be in its third option year.

So my question is more around um how vendor performance is evaluated each year before you all decide to exercise option years.

I mean, we have a formal process through Office of Contracts and Procurement where we assess on an annual basis.

Um, I have not had to do one of those myself in quite some time, so I can't speak to the specific questions.

I don't know if anyone on that team can, but we can um get back to you on that one.

But if we have significant issues throughout the the contract period, um, you know, we have different uh ways to address those.

One just typical oversight and monitoring.

If it escalates to a certain degree, then it's uh you know, corrective action plan or other letters of enforcement that we can issue.

Okay, but as you guys receive complaints throughout a contract year, are those being documented in some way such that it gets back to the OCP team because not necessarily with your agency, but I can think of other departments where we keep using the same contractor because nobody wrote anything down or shared anything with the OCP contract specialist, so they just assumed that everybody was satisfied with the performance when in fact it was a horrible contractor who probably should be disbarred, but here we are.

Um, for the specific contractor that you're speaking of, I'll follow up with you afterwards.

Okay, and then I can also follow up just generally on what the practice is, unless you nope.

Okay, we'll follow up.

All right, um, there was testimony uh raised concern around health care finances policy proposal to reduce the Medicaid bed hold for immediate care facilities for individuals with intellectual disabilities from 60 days to 18 days to align with the policy for nursing facilities.

Now your testimony noted that this will um result in a mere 134,000 dollar um savings for the district, but what was the overall reason for the change?

It couldn't have been financial, we didn't get enough out of it.

It was partly financial.

We're looking for savings in a budget where we had to come up with a lot of savings, but also from a policy perspective.

Um we couldn't um justify the difference between the two settings in terms of the policies.

It would you know, we'll be it just in a completely different patient population.

Yeah, but the the whether or not a bear hold day is a problem uh won't vary according to the nature of the patient.

Uh it is whether or not the, you know, if if if if there's a um a tension for use of those bears that would result in a person losing um their access to a bear, yeah, that creates a challenge.

We didn't think that was an issue.

So you're not concerned about any adverse effects around lowering the threshold?

No, I'm not concerned about it.

I it's uh to me that the to meet their policy has always been questionable, but not not just in DC, but uh nationwide.

Um, others will argue with me that is is desperately needed.

Um, maybe even some folks on my staff, but I think uh go it's not like we could we cut them to zero.

Um, you know, we basically equalized it with what you see on the school nursing facility side.

Okay.

Um healthcare finance noted a two million dollars in local savings in the FY27 budget for long-term care services by shifting payment structure to quality, not quantity.

So um some advocates have raised concerns that a bundled payment structure could lead to across the board pressures to reduce personal care aid service hours.

Um, how will health care finance ensure that beneficiaries with high needs will not lose their PCA hours?

And sure, um, and that's something that we're still deliberating internally as well.

But the goal, and this um was raised in one of our stakeholder meetings.

Um, our goal really, as you mentioned, is the quality over quantity and also recognizing that each individual has their own care needs, right?

We believe um likely that a bundled uh rate approach will allow a provider and the individual and or their family um supports too to really think about what makes the most sense in terms of care.

We do see a lot of personal care uh services uh utilized here in the district.

Um folks need it, we want to provide it, but there are other services that are available that aren't gonna, you know, necessarily, not gonna rehabilitate someone to like 20, um, but really can give you a better quality of life and function in terms of physical therapy or occupational therapy that can be supportive.

Or we can look at, or what we're looking at is also like what kind of um supports do we see um that our uh residents want.

Part of the the vendor that did we did bring on board, did uh not only a provider survey but also a beneficiary survey, and really just trying to have a better sense of what people uh appreciate, need and want, and and try to make that available to them.

Okay.

Um is this telegen that you're referring to?

No, no, okay.

The vendor that worked on the rate study.

Okay, all right.

Okay.

Now I do think we're done.

Okay, great.

All right.

Um, so I want to thank our government witness.

Oh god.

Okay.

Um, I want to thank our government witness um witnesses for testifying today.

Um, and um, you know, obviously, director, it's not goodbye, but I do want to publicly thank you for your years of dedicated service to the District of Columbia.

Thank you.

Um I don't know how many times you've testified before the council.

I mean, since 2011.

So, okay.

Well, this is just budget.

We'll see you for oversight in some other hearings uh before you get out of here.

Um, but thank you so much uh to all of you, and again, thank you to your team for making yourselves available a couple of weeks ago to answer some of the questions that we had, um, but also the constant communication about a variety of these different things.

Um, my colleagues often say, like, oh, health care, that's complicated, but y'all got it over there.

And I'm like, I wish um, well, we're holding on, but also, yes, it's complicated, and also um it's expensive.

So we are definitely doing our best on behalf of serving the residents in the district and making sure that people can continue to have um affordable um and clear coverage.

Okay, so um for the public, this concludes uh the budget performance, sorry, the budget hearings for the committee on health for the proposed fiscal year 2027 budget.

Um the committee will meet again on Wednesday, May 20th at 3 p.m.

Will we reconsider and vote on our committee's budget report recommendations?

Um, and then it will proceed to the full council uh thereafter.

Um so if um I think the deadline already passed for if you public witnesses to submit their written testimony, I think it's today at five o'clock, before the record closes, and you can do that um by written.

Uh there being no further business before the committee at this time.

Um the time is 12 24 p.m.

and this hearing is adjourned.

Thank you.

Yes.

All right.