Washington, D.C. (Delivered November 30, 2018) – About 14 million people get services from the various departments that we have. We have a $160 billion dollar budget and about 30,000 staff. California is a state that runs most of its social services programs through the counties. The 30,000 does not include the county staff, who are actually doing the eligibility determinations and running the various programs like Medicaid, SNAP, and TANF.
I was appointed Undersecretary of the Agency back in 2008 during the prior Administration. I was appointed by Arnold Schwarzenegger, confirmed by the Senate, and continued through the Brown Administration. June of this year, I was appointed as Secretary of Health and Human Services.
In 2008, California was in the middle of a recession. We were cutting billions of dollars out of the HHS programs. I had just come over from the Department of Finance where I spent 13 years so I was familiar with the budget process and how you go about reducing budgets and what that looks like.
I had a two hour meeting with the Secretary at the time, Kim Belshé. We were going through all of the various options of how we were going to reduce the budget. Options included changing who was eligible for Medicaid, what benefits they could get under Medicaid, reducing the hours of in-home health services, and unallocated reductions of developmental services. We were bucketing the reductions options, breaking them into A, B and C buckets. California was already going through a bad time, so everything that was easy and non-impactful had already been done. Bucket A was the stuff that was really quite bad. Bucket B was like this is terrible and this is really going to hurt people. If we had to do bucket C, it was time to leave; we need to pack up and get out of here.
We got done with that whole process. She looked at me and said, “Bucket A; what’s the cumulative impact?” Given my background, I rattled off how many billions of dollars the reductions were worth. She said, “That wasn’t the question. I am asking how many people and families are we hitting 2, 3, 4, 5 times if we do the reductions that are in that bucket.” I said, “I don’t know. I could tell you that this reduction in bucket A is going to hit 50,000 people, and this one is going to hit 150,000 people, and this one is going to hit 5 million. I don’t know how they nest together. I don’t have the overlap and don’t have the systems that are going to allow us to answer that question for you. I can tell you the average person receiving Medicaid looks like this. For example, their family size and their income level. That means they are probably eligible for these programs. I can knit together what an average looks like. I can put together, here is what the average impact looks like in bucket A, bucket B, and bucket C.” That was the best we could do. I also told her, “The worst thing is, after we are done, I still won’t be able to tell you. After we implement these reductions and we look back on what happened and you ask me that same question, I still would not have the answer for you. Because all that I am going to be able to tell you is the Medicaid enrollment went down by X number of people and the grants went down by X dollars. I’m still not going to be able to tell you how many people were hit five times by the reductions that we implemented in the budget.”
That is how things were in California. It’s really an uncomfortable place for decision-makers to be. It’s a really uncomfortable place for an Undersecretary to be if you are briefing first the Secretary and then the Governor. But that’s how it was. When I would ask my IT people, they would just tell me, “There is nothing you can do about that. That is just how the world works. We have got these big systems that don’t talk to each other. We don’t know what to tell you.” Which, going back on it now, I don’t think it was totally truthful.
I will also tell you that when I went to the Agency, one of the stipulations I had – there were two Undersecretaries at the time – was that I would not be the one that had IT. The other Undersecretary had to do IT because the whole process of IT Procurement in California, as in most places in government, is soul crushing (someone in crowd said, “crunching.” Mike said, “No, crushing; crunching is not bad enough.”) When we changed to only one Undersecretary under this Administration, I got the whole thing back. I started really trying to change the way that we do procurements in the state. We have since started to try to do iterative, modular, agile approaches to our procurements.
We launched Open Data about four years ago. Given my background, you can understand that I was not a champion of this entire movement at the time. In fact, I was probably the biggest opponent of it when it first came up. Mainly it was because whenever I dealt in data – remember I kept IT away from me – it was a data breach. Someone had left their laptop un-encrypted in a trunk and suddenly there were 10 million Medi-Cal identities out there. We would also ship unencrypted backup tapes and lose one. That is the context in which I dealt in data.
Terms are really important. When people come to you to pitch an idea and they say, “We want to open the data,” and your context is, “I deal with data breaches. I don’t want to open the data. I don’t want people getting access to your data.” Then they double down on you and say, “Well, hackers really like it and they can do wonderful things for us.” I am like, “No, hackers are bad.” Then they say, “No, they are good civic hackers.” The terminology is really awkward and really not good. But once you get past that, you start talking about open data and that it means transparency and people understand what we are doing. That I get and that I want to do.
I started to think about the data that we have and how we are using it. It got me back to that conversation that we had back in 2008 where I couldn’t answer those questions. I started rethinking and re-probing on those questions. Last year, a researcher from the University of Southern California spent half of her sabbatical at our Agency. She took data from eight of our programs, ran them through algorithms and figured out how to link them together. It was the first time we got a snapshot of the overlap of the data of our major programs and how many people are receiving those different services.
Since then, earlier this week we just put up on our website and our open data portal, a dashboard for Health and Human Services using GIS information to do that same sort of thing. We linked together all of the different programs that we have so you can get a snapshot of what the overlap looks like at a county, congressional district, legislative district level or statewide level. You can compare data across different districts or counties and what the demographics look like. There is lots of good information that we just posted. We finally are now in the great space where we are starting to link the data together and get a better picture at the client level.
Why is that important beyond the question that I had with the Secretary? We in government do a wonderful job at siloing things. We are really good at it. You really have to. It’s not a criticism. To run large organizations you have to have silos. Functionally, you can’t have a completely flat organization. To have structure, our organizations need departments, which need divisions, branches and programs. It makes sense why we do that. But my push back on all of my folks is that our clients’ lives aren’t siloed. They don’t care about our programs. They don’t care about our departments. They have needs. In some cases, they have multiple needs. We now have data that are showing how many have multiple needs. It should be our job to bridge those silos that we have set up for our convenience rather than making them go through a massive application process that makes no sense to most people and under the best of circumstances is difficult to navigate. When you come to us and enter one of our programs, you generally are not in the best of circumstances. We have set up these systems that make it incredibly difficult for people to find out what they are eligible for and make it incredibly difficult for them to apply for it.
I have been working with Code for America for a while. To understand the user perspective when going through the application process, they had someone apply for CalFresh, which is our SNAP program in California. He videotaped as he went through the whole convoluted application process in San Francisco. They partnered with the San Francisco Human Services Department. It’s actually an incredibly depressing video. It really, to this day, when I think about it, it is terrible what we put people through who really have genuine needs. I told them, “It’s far worse than you are portraying because your friend didn’t actually need it.”
We make it incredibly difficult for people to access information about their benefits or ask questions. Sometimes they have to sit on hold for hours in the middle of a work day, and we expect them to be holding down a job. How does that make any sense when you have to try to navigate some phone tree to figure out the benefit level of your EBT card. How does that make any sense when you cannot even find an ATM near you that is surcharge-free? It’s not an unsubstantial amount of their monthly income if you keep hitting them with surcharges. Those are the types of things that Code for America and we have been working on together. We really want to try to improve that experience. It is all about thinking about the client.
What I tell my folks, if you look at what we do, if you look at the enrollment process that has been set up, none of you can tell me, I hope, that we had thought about the client. There is no way that we thought about the client. We thought about the government or reporting requirements. We thought about the vendor. We thought about all sorts of things, but there is absolutely no way that we were thinking about the client experience when we designed those application processes. And that’s what we need to be changing. That’s what we need to be focused on. I tell my folks that they don’t have a job because there is a Department of Health Care Services or because there is Department of Social Services. You have jobs because there are people with needs. If we are not meeting those needs, then why are we here? It is not just to show up in a Governmental building and get a paycheck. Also, because California counties handle most of the client interactions, state workers are one step removed from the client. It is difficult to see that interaction, think about the clients, and reconnect with what the mission is. The mission is about providing people with a resource they need.
One of the challenges I pushed out to my folks, and have a small team working on it, is how do we have a better system where we can figure out what people are eligible for and how they access it? I want something that is broader than governmental programs. When someone comes to a county office and they are not eligible for SNAP, but they still have a food need, what do we tell them? What are the counties doing? Where are they referring them? I told my folks I want a 211 on steroids. We spent probably 6 months to a year, not hardcore doing it, but continuing to work through ideas, trying to figure out how to address that question. Then I met John Ohanian. I went down to San Diego and was down there for something else. I went to San Diego 211. I started listening to what they were doing and how they were approaching their job. They were doing applications for governmental programs, but they were also linking the community and other resources that we don’t have. That’s when I told my folks that we need to learn more about what San Diego 211 is doing and we need to start thinking about how we can partner with them.
In California, we have a new Governor coming in January. It’s an interesting time. The closer we get to it, the more introspection I am experiencing. You have short spans in these jobs. You don’t know how short it will be when you take the job. For me, it could be January, or it could be longer. You don’t know. I have been really trying to embed what we have done into structures that would exist whether I was around or not. I was careful from the time that I started doing Open Data to not make it about me. I did not want all of this to be revolving around me. We need to set up structures that will move this forward. We set up a Governance structure that all 12 Departments participate in. There are literally hundreds of people now who are involved in various aspects of Governance. We had a meeting where 200 people across the Agency showed up to volunteer on Governance. Some of my folks told me – one of them is in the room right now – that we should jazz this up. How are you going to get people to join this thing with a name like Governance? It’s so boring. With the change of Administration, if you have something that is how you do business, that survives. If you have a shiny object, that’s what people focus on. They either, depending on the Administration, change it, get rid of it or it gets co-opted.
For me, all of this has been about changing our culture and really trying to refocus our organization. Focus on the client, because that’s really what it’s all about, but also use that then to focus on how we do everything, such as how we approach our jobs and what we think is important about our jobs. That’s really been my push. It’s trying to get that first follower and many more followers so that when the leader’s not there, you still have this group that thinks this is how things get done; this is how you do business; this is how you provide services in California. I am incredibly proud of what we have done in the last 4 years particularly. I think it’s just been amazing. Not for anything about me, it’s all of the people that have jumped in. In a lot of ways, it’s about me providing them space to allow them to do what they knew they needed to do. They just didn’t have the air cover before to do it. That’s what I have been able to do. It’s really them. It’s their movement. It’s not mine. I’ve just been there to provide that space for them to be able to push their ideas forward.
Social determinants and bringing social services into the healthcare space is where we are all going. That requires the ability to have interoperable systems and to have data at the client level where you can really look at what is going on across a multitude of venues and areas. The data you need to do that is difficult but it is absolutely the right place to be going. I was at a healthcare conference about 6 months ago. There were these amazing presentations on artificial intelligence and machine learning that the health systems are getting into. My message to them was, if you want to talk about healthcare and you want to talk about changing your marginal cost, you are having the right conversation. If you want to talk about health, you aren’t. Because health isn’t about healthcare. Healthcare is access when your health has declined. Something happened to you that you have to go through the healthcare system. Health is about the environment that you live in and other social determinants.
If you want a real challenge and you want to get into health, you need to realize the government and social services are way, way behind you in using data and accessing these kinds of approaches. You have the resources. Social service agencies don’t have the huge budgets that they can invest into artificial intelligence. They just don’t. It’s making that case of where the partnership of the healthcare system and social services are and why it is in their best interest to bridge that gap in health and social services. We need to start improving in data stewardship, technology, and think about the possibilities. We need to work together towards creating that space and the resources to really allow that bridge to form because that’s where we will start to get health. That’s where I think we will have the potential to really rein in the cost of the overall system.
That’s where, frankly, the United States is different than a lot of other nations. We spend a lot on healthcare. We don’t spend relatively that much on the social services. I’m not naïve enough to think we are going to flip all of that around, but I do think that we need to start making a case to the healthcare providers that you are only tinkering on the margin when you focus on healthcare and the things that are driving you in that environment. You really need to think upstream to social determinants and what is causing people to come into the system. Once you address that, you can start bringing down the costs. And by the way, have a healthier society overall. That’s what I think the promise is around interoperability and stepping back and thinking about the broader system, rather than on all of these disparate systems.