Next head of NH DHHS faces many issues

  • In this June 15, 2016, file photo, Health and Human Services Commissioner Jeffrey A. Meyers speaks to the Executive Council in Concord. Meyers announced on Monday that he will not seek reappointment when his term expires later this year.

Monitor staff
Published: 10/20/2019 10:21:30 PM

Health and Human Services Commissioner Jeffrey Meyers stepped into the job at a time of crisis. He never intended to stay long.

“I got appointed for a term – at the time, I told my family I was only going to serve one term,” he said in an interview Monday. “I think this is a job that demands 24/7 attention… But the pace of it is such that I really believe at the end of the day it’s a job that’s intended to be one term.” 

Now, with an announcement Monday that Meyers will not seek a second four-year term and will leave the post in December, the search for Meyers’ successor is on, according to the governor’s office. Whoever it is will have a lot to juggle.

Meyers came into office facing a trio of problems: a rising opioid epidemic, a beleaguered Division of Child and Family Services facing outside scrutiny after immense case backlogs, and an unwieldy waitlist of mental health patients, many held against their will in hospital emergency rooms.

How well he’s done cleaning up those categories is a matter of perspective. But maintaining those efforts and initiating new ones will be up to the next leader.

Here are some of the most pressing issues on the next health commissioner’s plate:

Back of the budget cut

Right off the bat, Meyers’ successor will have to deal with a slight inconvenience: a $25 million reduction to the department’s budget, courtesy of the budget agreement signed. That cut was made in part to help fund Medicaid rate increases and appropriations to schools and towns, and it was justified by lawmakers on the basis that the Department had returned a significant amount of unused money – more than $90 million – at the end of the latest fiscal year. 

The cuts can’t affect developmental disabilities, Medicaid rates or any county programs. But even if $25 million is a small amount to give up by recent standards, it’s still a lot to grapple with.

“A $25 million expenditure reduction is a concern,” Meyers said, adding that “we were the only department that got a back of the budget cut.”  

“Lapses” are standard fare for department heads in New Hampshire – they’re the target amount that departments give back to the general fund at the end of every biennium. But Meyers said because of the new cut, DHHS has to absorb “roughly $10 to $12 million” in reduced expenditures compared to what needed to lapse in the last budget.

Asked about the cut, Senate Finance Chairman Lou D’Allesandro defended the decision, first proposed in the final weeks of the budget showdown.

“It’s doable,” D’Allesandro said. “It has to be done. And if you look at what was lapsed in the last biennium, it was significant.” 

“...Hey listen it’s a tough job; there’s no question about that,” the Manchester Democrat continued. “But things had to be done, had to be put in place, we needed the rate increases, we had to deal with all the other things that were required by the department and in addresing those one of the ways to do it was the back of the budget cut.”

Meyers said working within the new boundaries will be a key test for the newcomer. 

“Those types of things obviously are going to have to be dealt with by the next commissioner, and I think that people are going to need to focus on it,” Meyers said.

Medicaid expansion questions

New Hampshire’s Medicaid expansion program, first authorized in 2014, received a new lease in 2018, when lawmakers voted to extend it by five years into 2023. But that doesn’t mean there aren’t tricky areas for DHHS to navigate. 

For one, there’s the New Hampshire Health Protection Trust Fund. That’s the fund that holds the federal money New Hampshire receives into the program – the account that pays out the hundreds of millions of dollars of claims that cover everything from substance abuse treatment to primary care for 50,000 Granite Staters making up to 138% of the poverty line.

Keeping that fund solvent while meeting the state’s 10% match rate to unlock the federal funding has been a delicate challenge practically every year the program has been in effect. But a major Democratic priority this year could be making that harder. By increasing the reimbursement rate for Medicaid services by 6.2% over two years, the Legislature and governor have also increased how much must be paid out of the trust fund. 

To meet that new spending requirement without breaking a cardinal rule of New Hampshire’s Medicaid expansion – don’t use general funds to pay for the state’s share – lawmakers have opened the possibility of allowing transfers from the state’s liquor commission profits if necessary. 

Meanwhile, an ongoing legal battle in federal court in Washington over whether New Hampshire’s Medicaid expansion work requirement passes legal muster will continue to consume the department for years – even if, for now, a ruling this summer has put the work requirement on hold. 

Despite some of the headwinds, Meyers said the Medicaid expansion program is in a “good place,” arguing that there is “tremendous support” for it in the state. 

“Look, the courts are going to sort out the work requirement. I think that’s going to take at least the next couple of years,” he said. “And we’ll see what happens with that.”

Reacting to the trust fund, Meyers said the state is “fine at the moment,” but added there could be “an issue over time” with its solvency. 

That’s because the growth of the trust fund is capped – by liquor sales and the insurance premium tax, both of which will stay static. Translation: If the cost of New Hampshire’s Medicaid expansion program increases, it may be hard to maintain the necessary trust fund without the need for general fund dollars, something supporters have long disavowed. 

And if the trust fund runs out, per state law, the entire program ends. 

Some of that growth is a result of the Medicaid reimbursement rate hikes, something pushed for by provider groups but which Meyers and Sununu had resisted in favor of targeted increases.

But Meyers said for now, the balance should work. 

“I think the trust fund is fine right now, even with the (increases) but over time it’s gotta be looked at very closely,” Meyers said. 

DCYF reform

Earlier this year, lawmakers established 57 new child protective service workers and 20 supervisors at the state’s Division for Children Youth and Families, which has been burdened with high caseloads and turnover and a consensus that more employees are needed. The new positions are welcome to the department – but many are still in the process of being filled.

Meyers has touted a series of job fairs in and out of the state that the department says have been well attended, and said more progress is expected in coming months. But with vacancies persisting, the effort is far from over.

The Families First Act

Coming to New Hampshire in 2021: a new federal deadline. The Family First Prevention Services Act, signed by President Donald Trump as part of a federal budget bill in 2018, requires states to upgrade their group home and foster care systems or lose out on federal money. That means redesigning systems of care and building up community services and foster homes to attempt to reduce the use of group homes throughout the state.

The department has put out a request for information, but choosing and implementing that system will be a much bigger lift.

​Psychiatric hospital

The compromise budget put aside $8.8 million to build a new forensic psychiatric hospital in New Hampshire – around half the money. Designing a building and beginning construction, not to mention putting pressure on the Legislature to secure the rest of the funding next year, will fall on the next commissioner.

Developmental Disabilities

For years, New Hampshire’s Developmental Disabilities services were severely backed up.

“At the end of the prior biennium, the department had left about $20 million unspent in the Developmental Disability fund, which when matched with federal funds as about $40 million. And so I really inherited a mess when I first took over in DD funding.”

Improving that “mess” didn’t happen overnight.

State fiscal year 2017 started with 32 people on the list and still ended with 30. Fiscal year 2018 started with 30 and ended with 26.

But change finally happened in 2018, after the Legislature appropriated funds to DD services during a year of high surplus. In one year, the wait list dropped from 26 to zero.

Still, the services are in demand. This summer’s three-month continuing resolution after the budget veto put on hold new services, and a waitlist remains: 21 newly eligible people are on the list, and 72 people need additional services, according to Department of Health and Human Services statistics.

With the compromise budget signed Sept. 26, the Department now has the means to keep those services going. The next commissioner will have to make sure they do.

Overall spending

DHHS faces a challenge much more universal than any one program: revenue projections. A historically flush year of surplus revenue this year allowed budget writers to build in major spending increases, from Medicaid reimbursement rates and school funding. 

But that surplus – driven largely by one-off repatriation tax incentives following federal tax reform in 2017 – is already dwindling. The latest monthly revenue figures from the state’s Department of Administrative Services, released for September, indicate that overall general and education revenues are already down $26.7 million from where they were expected to be. 

And, absent new revenue sources, that means likely long term funding constraints at New Hampshire’s health department. 

Faced with that hypothetical, Meyers argued the ability of the Department to weather such challenges expands beyond any one position. 

“I’ve built a team in the department – a leadership team – that I’m incredibly proud of, and value, and that are very capable of moving and advancing all of these efforts in the coming months,” he said. 

And he said that the programs that have been built up in recent years – while in some cases expansive – are not under threat. 

“I think in leaner times, sure, there’ll be difficult choices to make,” he said. “But that doesn’t mean the investments that have been started now are not sustainable. I think there’s really an expectation of the public as well as stakeholders that we have to maintain our investments.” 

Whether that happens in reality will be soon out of his hands.

(Ethan DeWitt can be reached at edewitt@cmonitor.com, at (603) 369-3307, or on Twitter at @edewittNH.) 

 




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