♪♪ She leads the state's largest agency, one that thousands of Iowans interact with on a daily basis.

We'll visit with Kelly Garcia, Director of the Iowa Department of Health and Human Services on this edition of Iowa Press.

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♪♪ For decades, Iowa Press has brought you political leaders and newsmakers from across Iowa and beyond.

Celebrating 50 years of broadcast excellence on statewide Iowa PBS, this is the Friday, May 24th edition of Iowa Press.

Here is Kay Henderson.

♪♪ Henderson: Our guest became Director of the Department of Human Services in November of 2019.

She is now the Director of a merged agency, the Department of Health and Human Services.

Kelly Garcia, welcome to Iowa Press.

Garcia: Thank you so much for having me, Kay.

Henderson: Also joining the conversation are Michaela Ramm, she is the Health Reporter for the Des Moines Register.

And Erin Murphy, the Des Moines Bureau Chief for the Gazette in Cedar Rapids.

Murphy: Director Garcia, your agency is undergoing a big change right now in the redesign of the state's mental health and behavioral health systems.

Tell us a little bit about that process and the timeline for how those departments, those services are being merged and what that will look like for Iowans.

Garcia: Absolutely, Erin.

So, this work comes after years of evaluation.

So, I want Iowans to know this was a very thoughtful and methodical process.

We brought this work to the Governor and, as you well know, this is at the forefront of her focus.

Behavioral health for all Iowans has been part of her vision from the moment I stepped foot in Iowa back in 2019.

And we're there now.

So, we did some really intense evaluation.

What are the gaps in Iowa?

And what we saw was a fractured system where regional designs, which is great because it gets you close to the needs of the community, but it also means that some communities have different services than others.

And what we want here is for Iowans to have equal access no matter where they live and what their needs are.

We shouldn't have county or region barriers to that system.

We brought that design to the Governor and the legislature and she enthusiastically endorsed it last week at a signing ceremony.

The timeline kicks off a year worth of transition.

And so come July of next year we will have a newly redesigned system.

Will that be final?

No.

We will be in a mode of continuous improvement and deep evaluation to ensure that all Iowans have access to services.

Murphy: And that is exactly what I wanted to ask.

How does this new system ensure that Iowans in all areas of the state, urban, rural, northwest, southeast, have access to these services and the same services no matter where they are?

Garcia: Two really key changes that allow us to do that and then some philosophical and kind of deep organizational shifts in our own agency that matter to ensure that that occurs.

So, one is we take those regional boards that people know today and we shift them to districts.

We have a map, but we lift the barriers of the map that exist today.

And instead, what we look at is access points because access is what matters to Iowans.

Can I go where I need to go?

And do I get the service delivery I need?

Is my family well cared for?

And so that regular evaluation will come from the state now instead of just a regional design.

We'll be looking at the entirety of the state.

The fabric of the agency change for us is that we now have a deep-rooted system internal to our organization to ensure that that measurement is regularly occurring.

And we don't wait for a cataclysmic event to decide whether the system is working or not.

Ramm: A major barrier to care for many Iowans is just the lack of availability of providers to actually offer that care.

So, as you're working on this alignment effort, how is your agency working to recruit the necessary workforce to provide that behavioral health care for Iowans?

Garcia: So, this is a really big issue that our agency holds I think a key seat at the table in, but we obviously cannot change this for Iowans by ourselves.

This is going to be a really thoughtful design that is going to take many partners.

I think about it, Michaela, in two really key ways.

One is of course the kinds of controls we have through our operation of things like the Medicaid program.

We're a major insurance line in Iowa and so we have lifted those barriers on telehealth, which allow clinicians from across the United States to come into Iowa and provide services.

But telehealth can't solve all our problems.

So, we do have to think about that pipeline build.

And our agency can play a key role there too in two ways.

One, rates through the Medicaid program.

It's not the only way to solve provider access issues, but it's a significant one.

And we now have a regular way of bringing forward to the Governor and the legislature, what do our rates look like as compared to other states, border states, other programs and other analogous states of size and structure?

We also are a major employer.

We operate our own health care facilities.

And so, we have now launched some really deep and meaningful residency rotation and other clinical programs where clinicians who are training at the University of Iowa and other schools here in the Des Moines metro area, come into our facilities, train and then some of them stay.

And you couple that with other strategies.

We have an actual plan around ensuring that we really make a broader portfolio of this child psychiatrists that we know we don't have enough of.

Henderson: Lawmakers did not provide more money for the system.

However, we learned there's about $20 million of unspent funds that could be used.

How will they be used?

Garcia: So that analysis was key to this discussion.

I get asked all the time, do we need more money in the system?

And the answer is, I don't know, I can't tell you quite yet.

What we see there, Kay, is unspent balances and some duplication of funding as well.

And so, we're teasing through that now that we'll be able to see it at a deeper level.

And then that measurement comes into play because we may need more money in the system, but today I can't see all of it.

So, clarifying where that money is going, ensuring that we're paying for evidence-based practices and that we're able to draw down federal match in places where that makes sense.

Teasing out what services can be provided by Medicaid or other insurance lines versus what needs to come through this new structure, is exactly what the goal of the next year is.

Henderson: There has been so much focus on the part of this that is for people who need mental health care and for people who need substance use treatment.

Also included in this is service that the state provides people with disabilities.

Explain that.

Garcia: Absolutely.

So, this is an area of intense focus in our agency in many ways.

Individuals with disabilities have very unique needs.

And while I think we know that as a system and I think Iowans understand that, the structures that are there to support that experience, which often includes not just the individual but their family, are not as mature as we might see in other spaces.

And so, this bill starts to change that in really significant ways.

We shift the disability work out and over to a new structure in our organization because we do have all of this within our agency now, all of these sets and services and lifespan services, and we start to create the way I kind of refer to it is a brightly lit path.

If you have a child who is born with a disability, where do you go to even understand the system and the resources that are available to you?

What we will be creating there is exactly that, taking what is already here and just really maturing it and making sure that that bright line spotlight is there for Iowans to understand how to access services.

Henderson: How does this interact with the changes that have been made to the Area Education Agencies, which provide services to students with disabilities?

Garcia: So, Director Snow and I will be walking -- Henderson: She is the Director of the Iowa Department of Education, for folks who may not be familiar with her.

Garcia: Correct, absolutely.

And you heard me during the session, I testified in those subcommittees.

Why?

Because there are no two systems in state government that need to be more closely linked than education and health and human services.

And at the core of that is services for children, whether we're talking about behavioral health or children with disabilities, other types of disabilities.

That linkage, because children need services in their natural environment, which means home with their caregiver, school because that's where they're there most of the day, most of the waking hours, and then in the community.

And that is a very complicated framework.

We have some work to do to make sure that that connection is really there with our AEA partners.

Murphy: And that's a perfect segway to what I wanted to ask you about next, which is speaking of children's mental health care needs, we still don't have a statewide system in Iowa of children's mental health care delivery.

That has been talked about in the legislature, but has never been formalized, I guess.

Why not?

And how important is something like that to have to ensure that these children, like you said, are getting the services where and when they need them?

Garcia: The focus on children couldn't be more important, that children are not just short adults, they have very specific needs and when we're thinking about the needs of youth and children, also little adolescents and older youth, we're also thinking about family systems because you can't ignore the fact that children are at home with their parents.

And so, there is an array of services that extend beyond the child we're talking about.

Iowa has done some really deep work in this area.

But I want to make some, make sure that we're kind of working from the same framework.

So, the MHGS regions have been responsible for the children's system, except that most children in Iowa receive that service through the Medicaid program.

And so, when I talked about fractured systems, that is one of the ways it is fractured.

The payer source is over here through the Medicaid program, but the service array and design was being built in a separate system.

And in legacy DHS that was not as maturely connected as perhaps it should have been, although we have also had some really significant events in our history that have changed the landscape of the way we think about the need for behavioral health services.

The good news is our agency is positioned to do that deep and thoughtful work now.

We have the right people in the right chairs to do that work and intense focus and a phenomenal amount of advocates, family members and youth, with lived experience, that are bringing that voice to the table and we're taking it very seriously in this redesign.

Murphy: And so, what does that look like moving forward?

What needs to take place in your view based on that feedback that you have been getting so far?

Garcia: So, a few things, and I'm going to separate out some of the work on the behavioral health redesign, and kind of turn our focus over to Medicaid waiver redesign.

And the reason we launched that together is because these systems have to work together.

So, Medicaid waivers support individuals with intense level of needs to stay in their home, to stay closest to those they love and in their communities.

Iowa has seven Medicaid waivers.

Fun fact here, Iowa is home to Medicaid waivers, which is a beautiful and rich kind of history piece in what these services can provide to individuals with disabilities and intense needs.

But they're complicated in structure and, in fact, not really meeting the needs of Iowans today.

So, we have been working on this codesign with our behavioral health redesign to think about that, move from diagnosis based to need based, and in that review process we brought Iowans and Medicaid members to the table to help us design what services they need.

And that is all centered around unique needs of the individual instead of thinking and sitting in Des Moines in a boardroom and designing these things absent the Iowans we serve every day.

Ramm: Your agency is preparing to close Glenwood Resource Center, the state-run institution for individuals with intellectual and physical disabilities.

Can you speak to how your agency is making sure the residents who were living at Glenwood are finding adequate care at their new placements?

Garcia: Absolutely.

So today on our campus we have 23 individuals who call Glenwood home and in a very short number of weeks that will come to zero.

I really want to start by saying what I hope the story is when people look in the history books around Glenwood is the heroic level of work by our employees.

To do that work every day, even in its history, which is long, is a calling.

To do it in the face of known closure is heroic and it's nothing short of that.

This opportunity, though, really catalyzed the agency's deep and meaningful work around rebalancing and investment in home and community-based services.

So, in order to do this, we have to think about the unique needs of an individual, make sure that that work is personalized in every way and then work with our incredible network of providers to ensure that it's available across all parts of Iowa, not just centered in one section of the state.

But if someone likes to fish and wants to live close to mom and dad, we need to think about how to make that happen.

And we've done that.

Glenwood was a catalyzing event to have that conversation and I'm delighted to say the Governor has made historic level investments in home and community-based services and will continue that journey.

Ramm: And Glenwood is still on track to close next month, correct?

Garcia: It is.

Henderson: Turning to the mental health institutes that you oversee in Cherokee and Independence, there were two others that were closed before you arrived on the scene in Iowa in Clarinda and in Mount Pleasant.

We had some guests on this program several weeks ago who are advocates for people with mental illness and they say that the private sector is not providing the long-term care that is available in the mental health institutes.

Would it be time to think about the state reopening a mental health institute in southern Iowa?

Garcia: So, I don't know that we would redesign those legacy structures to be that gap filler.

But are we thinking about the needs of long-term service supports?

Yes, deeply, and with some of those advocates seated right beside us, they are partners in this discussion.

We're thinking a lot about what can be in our campus, on our two campuses.

We have large campuses with other buildings and a unique way to support other types of step-down care.

But that really smaller setting, highly specialized, well-staffed, but close to those higher-level clinical connections, is absolutely something that we're intent on building out.

We're having some deep conversations with the legislature on opportunities to do that.

And I see that being a predominant theme next session.

Murphy: Director, we're in the process of adjustments to Medicaid post-pandemic.

There was a rule during the pandemic that people could not be disenrolled and that rule has since lifted.

And so more than 280,000 Iowans have been disenrolled from Medicaid.

I wanted to ask, what is your department doing to make sure, because we've heard of cases where people were unaware this was coming and maybe should still be eligible and have had to re-enroll.

Are they working through that process?

Is your department helping those types of people especially work through that process?

Garcia: All day, every day, Erin.

That's our job.

We work with Iowans who need to navigate the eligibility process every day.

In terms of disenrollment, the individuals who were disenrolled were ineligible for Medicaid and we had a very robust plan around ensuring that individuals knew that that was coming, in so far as in certain circumstances we went and knocked on doors to make sure that we weren't missing vulnerable Iowans that needed that coverage and were eligible for it because that is our job, that is our core function.

But in this pathway, we also have a network of other providers for service, including direct referrals to the marketplace that picks up that coverage.

Murphy: And to that, is there any way for the department to know how many of those folks have successfully then found other types of coverage?

Garcia: We can see coverage line -- we are lucky in Iowa, we have a very low uninsured rate, very low as compared to other states.

And so absolutely, we keep an eye on those metrics all the time and are looking at that when we think about kind of the health and access points when we do our work from a public health perspective when we're thinking about all Iowans.

Murphy: And last on this, I'm reading an Iowa Public Radio report that said 18% of Iowans who had been disenrolled had been reinstated in Medicaid, so those were the folks that may have been unaware, whatever reason, now they're back.

Is that roughly, I don't know if your agency had expectations?

What does that number say to you?

Garcia: So, I think what we see when we look at it -- and yes, we did a lot of modeling around what we expected to forecast in this work because we're constantly paying attention to individuals who have gone back to work, and we could see that many had.

We also look at utilization.

We had members enrolled for a long period of time through the public health emergency that utilized nothing during that time.

Why?

Because they were working and they had other dual insurance and they didn't need Medicaid any longer.

That's the story.

And so, we are constantly looking at those types of metrics.

I would say that our forecast was really successful in thinking about who would stay on and who wouldn't.

And now we're doing a next phase of deeper analysis around that continuum of what Medicaid provides in the state.

Ramm: The federal government has recently approved nurse staffing mandates for nursing homes across the country.

Nursing homes in Iowa, they have faced a lot of challenges, and they say this new mandate will be another hardship.

So, will the administration raise reimbursement rates to help nursing homes be able to meet these new staffing mandates?

Garcia: So, our nursing facilities in this state have a statutory requirement around regular rate review and that actually comes next session.

So, we do that analysis and work to provide the legislature and the Governor with that detailed methodology around what costs are for that care, for delivering that care.

So that is part of a regular analysis.

Obviously, these new requirements push additional costs and so that will be accompanied in the analysis for next session.

Ramm: And there has been continued conversation about the state of the nursing home industry in Iowa, the availability of those services.

So, I wondered how your agency is looking at that particular issue and how it's working to stabilize the industry, especially as Iowans' population continues to age.

Garcia: Our biggest focus is on quality, Michaela.

So, everything we do, because we are a major payer source for nursing facilities in the state, is really focused around dollars that invest in quality care.

We know that is what individuals expect and what family members want for their loved ones.

And so, we have a variety of different initiatives through the Medicaid program that really hone in and focus on that.

We do see significant changes in the need for nursing facilities, bed capacity that is lower than makes a sustainable business operation.

And so, we work with the Association of Health Care Providers, we work with individual nursing facilities on those transition plans as desires of what Iowans want shift.

Most Iowans are saying they want to stay at home.

And so, when we think about that rebalancing of home and community-based services along with institutional settings, it's not an either this or this, it is a network.

We have to have a full continuum and all parts have to be strong.

Henderson: In December when the Governor turned down federal assistance to provide food in the summertime months for children, she said one reason she did so was because the federal plan did not address childhood obesity.

Now that there are state led feeding programs during the summer, are those programs and your agency ensuring that childhood obesity is addressed?

Garcia: Absolutely, it's at the top of our list through our public health work and our state's medical director is keenly focused on this area.

We see very poor outcomes for children and adults in the state of Iowa and it is at the top of our list in terms of addressing on when we think about prevention and early intervention.

Nutrition is one aspect of those key components.

Henderson: So how are you doing that?

Are you ensuring that the food that they buy is fresh food, fruits and vegetables?

Or how are you doing that?

Garcia: So, through those direct programs that are school based, in fact I'm touring one this afternoon, we do, we lay eyes on kids, which is also really important to make sure that other social determinants are being met just beyond the nutrition and food component of work especially over the summer.

We also think about other levers we have in the agency, incentives for buying that fresh produce, for thinking about nutrition core to what is available, for example, in SNAP, which is fairly wide open.

And there's important agency in individuals being able to buy what they want and need, but there is a lot of education to be done around how to do that and food preparation, ease and access as well.

And we are working with a variety of different partners to ensure that that's the case here in this state.

Henderson: This month the Governor signed a bill about meat labeling.

In that bill is a directive to your agency to apply for a waiver from the USDA to prevent federal food assistance being used to buy, I guess, fake eggs.

Have you applied for that waiver?

And what are its prospects?

Garcia: That waiver is in process and that will be up to our partners at Food Nutrition Services to make a decision on.

Henderson: Have other states done this?

Garcia: Not that I'm aware of, but it is certainly a conversation in other states right now.

Murphy: Director, when we talk to county supervisors, they often talk about the challenges at the 99-county level of issuing some of their services and one that has come up among that is public health services, which with the department merger is now included in your department.

I'm wondering if you foresee a future in Iowa where those currently county level public health services are more of a regional delivery system?

Garcia: I do.

I do, but they warrant really intense conversations.

And so, we are actually, that is an area we're focusing on this summer as we go out and about in what I refer to as a summer tour, to hear from Iowans and officials at the local level on how that's working and when it's not.

What we don't want to do is strip away, again, that close community connection.

That means that public health has to have a presence in every single county full stop, it has to.

But we learned during the pandemic, and I saw this firsthand, that the bench wasn't there in every area and to be prepared for whatever is coming next, whether that be an emergency response like we're seeing in real time today, we have to have strong partners in every county -- Murphy: And you're talking about the response to the storms that we've had in Iowa.

Garcia: Yes, I am.

And that happens, it happens with regularity, whether it be natural or manmade disaster or another emerging disease and we have to think about having strong systems that can respond.

Iowans always come together, so that is there.

I think we're seeing it today in Greenfield.

And that is a wonderful aspect of Iowa's very unique culture.

But we want those government systems to be equally prepared to respond.

Henderson: We have about a minute left.

Immunization rates have been falling.

How is your agency going to reach out to Iowans to discuss the falling immunization rates?

Garcia: Well, we already are and we're doing that work through our Medical Director, Dr. Robert Kruse, talking about the need for preventing disease and having those rich conversations with your physician, trusted partners in your health care community, and that is incredibly important to us.

Henderson: Which one is more concerning, measles, mumps and rubella or which one is most concerning to you?

Garcia: Measles is, as you know, I'm sure you've seen in the news that there are measles outbreaks in bordering states, and so that is high on our list to ensure that we're prepared and that we have the proper response tools on board in our agency and in our state, and we do.

Henderson: Kelly Garcia, thank you for joining us on this edition of Iowa Press.

We're out of time.

Garcia: Thank you so much for having me.

Henderson: You may watch every episode of Iowa Press at iowapbs.org.

For everyone here at Iowa PBS, thanks for watching today.

♪♪ ♪♪ ♪♪ Funding for Iowa Press was provided by Friends, the Iowa PBS Foundation.

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