Jennifer Colamonico
Welcome to HMS Vital Viewpoints on Healthcare. Concise conversations with experts that identify practical solutions to make health care and human services work better. I'm your host, Jennifer Colamonico, and I'm thrilled to be your guide as we explore new ideas for solving challenges that confound our uniquely American systems charged with delivering health and healthcare in a world that has far too much information and far too little wisdom.
We'll aim to keep it simple, frank conversations about what it really takes to reimagine these systems of health and health care. Our experts know how things work and don't work, and they have viewpoints on both the problems and solutions that are born from that experience. Vital viewpoints on healthcare is not just another podcast. Is your window into the minds of those steering us toward a healthier future?
Subscribe now and together we will explore the hard earned wisdom that could change the way you think about your professional challenges. Uma Ahluwalia leads our Human Services practice at HMA. She is the managing principal in our Baltimore office. Uma is a health care and human services expert with extensive experience leading growth initiatives in both political and legislative environments, where she's developed innovative, cost effective solutions and public policy strategies.
Uma was previously the director of Montgomery County Department of Health and Human Services in Maryland, where she implemented the Affordable Care Act and managed public private partnerships. She has also held leadership roles with Washington, DC's Child and Family Services Agency, and was the assistant Secretary of the Department of Social and Health Services in the State of Washington. Uma, I'm thrilled to have you on the podcast today.
We've done great work together, and, I'm just really interested to get more, insight into how you arrived at this, at this job. So, maybe start with tell us a little bit about how you got your start in, in, child services, child welfare. However, you, you sort of frame that, but I'd love to just know how you got your start and kind of when you knew you really had a passion for doing this work.
Uma Ahluwalia
Yeah. So I came to the US in 1989 and with a master's degree in social work and started sort of he might do is is the better word, in nonprofit and for profit sector as did work in aging and disability, as developmental disability still diagnoses and then works in a nursing home as the director of social services.
And at that time, I thought I wanted to be a nursing home administrator and actually went and got my master's in health administration and long term care, and then decided that I really couldn't let go of my social work roots. And so I went to work for an area agency on aging while I was there at that organization had a just a fantastic organization in northwest DC, but it had a very large board, and they wanted to diversify funding streams.
Right. And at the same time, they were reluctant to let go of their charitable work and their community benefit, if you will. And so one day, in a fit of pique, I applied for a job in county government in the county where I lived for a deputy director for the local Department of Social Services as child, adult and Family services deputy.
And I had managed a group of 11 people and this was like 300 people. And I don't know what my boss then saw in me, but he took a chance and I became the deputy. I first interviewed like I thought was, I'm never going to get this job, so let me go have a good time. And I did, and then I wanted it so badly and they took a good minute to give it to me.
And then once they got it, I one of the first things someone on staff did was very smart. They took me with them to Cleveland to see an initiative called family. The family by the Annie Casey Foundation, which was a child welfare reform and transformation initiative that was blossoming all across the country. And it's sort of its origins were in Cleveland and that was the moment for me.
Right. Like I seeing what was possible for children who were abused and neglected, for families who were struggling economically with social emotional well-being, with substance use, with a whole host of issues. And that sort of started my journey. And so I got treated deeply, and I had adult Protective services on welfare under my watch. And, and always in those environments, you know, child welfare, the risk of child fatalities tends to sort of tick, you know, prominence, if you will, in the work that you do.
And so that was really the start. And then I, I got deeper and deeper and deeper into child welfare. I got involved with the to KC foundations and KC and KC family programs with a bunch of national human service organizations. You know, went on to serve on the board of a few organizations, still serve on the board of a few serving organizations, the National Children's Alliance and the center for Adoption Support and Education.
So it's just then become a lifelong journey. Our oldest daughter is adopted. And so I have like a particular affinity to children's work and children don't come without families. Right. So you can't just talk about kids without talking about families too.
Jennifer Colamonico
So that's a really interesting and like, seemingly obvious statement. And yet it's interesting how much our our policy kind of doesn't always reflect that. So maybe talk a little bit about, you know, how you really frame the issue, about, you know, what, what government agencies need to do to better serve children.
Uma Ahluwalia
From a child welfare lens. Right? I would say a state can never be as good a parent as a parent can be to their children. And I mean all manner of parents, right? Birth parents, adoptive parents, guardians like people who love their children. The state's always going to be a proxy, right? So I think our first line of defense always has to be how do we strengthen families?
How do we build resiliency? How do we build protective factors? Sometimes those factors are economic and poverty. Right. You know, poverty is something I think everybody acknowledges. The lack of economic resources in a family creates considerable harm, generational trauma. We talk about this all the time. If you're worried about how you're going to put food on the table and put a roof over your head, how are you going to think about higher level functions like mental health or, you know, how do I do civic engagement and how do I make my voice heard?
All those things are so important, but where do you have the opportunity to do any of that? And so I do think that when you have economic hardship and then you overlay that with indicators such as race, such as sexual orientation, the harms that come with mental health or, you know, domestic violence, those, those are all sort of compounding that underlying harm caused by deep poverty.
And so you cannot come at the issue of improving lives of children, creating safety, creating well-being without talking about stabilizing their families and building some economic opportunity and mobility for the parents.
Jennifer Colamonico
We spend a lot of our time around trying to improve health, and we know that health is about more than just health care, right? And I think the industry, of course, we've all gotten to the place where we're very comfortable talking about, health related social needs. I mean, we're comfortable talking about them. We're still working on doing something about it, but, you know, we're we're at least making those connections.
And it seems like so many of those connections go back to children and families, whether it's, you know, adverse childhood experiences that create health problems down the line or mental health problems, whether it's, you know, you mentioned poverty, you mentioned, you know, access to food, all of those are health determinants. And so, and a lot of them, of course, you know, when, when, you know, children can develop later problems because of, you know, what they've experienced.
So I guess, you know, the question is, how do we restructure the services that we're providing, presumably the services that you were providing to children and families? You know, we're we always want to do it better. And so, you know, what do you see? The biggest obstacles are right now, to getting, I guess, helping government do a better job.
I mean, you make a great point. Government is never going to be as good as the parents, but it has its role. So as stewards of the public purse, how do we do a better job providing those services?
Uma Ahluwalia
Yeah. So I'm going to tell you a little story. It's a little, little bit of a detour about when I was in the District of Columbia, I had only the child and Family Services Agency, which was the child welfare agency, and I leave that to come to Montgomery County, which is an integrated public health and human services department.
So it had everything saying aging and disabilities, behavioral health, child welfare, public health, homeless services, right. You name it, birth to death. We were at we were doing a and I remember having a conversation with the vice president at Casey Family Programs, which is the foundation, saying, hey, like we've talked for a long time about the fact that child welfare alone cannot solve these issues, right?
The schools are involved, public safety is involved. Sometimes courts are in there. All these entities behavioral health needs are there in families. Poverty needs are there. And here I have the opportunity to integrate all of it, to serve children and families and it was a value proposition. That, to me holds true even today. I think doing siloed delivery systems, whether it's just child welfare here, just Medicaid here, or just behavioral health there, fails to recognize the interconnectedness that exists.
Right? Mrs. Smith does not care where the funding is coming from or who's going to screen her, or who's going to deliver the services she needs the service she needs the service for her disabled child. She needs services. If it's domestic violence situation, she needs to be protected. But she doesn't need our children taken away because she failed to protect the child when she was barely holding on to keep herself safe in that environment, or when she decides to take a stand and loses our economic stability because our partner is no longer in the home, how are we going to make sure that she can stand on her own and take care of her children?
You know, those are all things that sit not in the child welfare bucket, but outside of. And so that increasingly brought me to this space of integration. And when we were in county, we were nationally recognized for our work of integrating public health with human services. We built an integrated case management system. We built a practice model around integration that was really intended to serve the whole family.
That's true for adults, too. And senior adults with disabilities. Seniors, right. Nobody just comes to a public agency, give me a vaccine shot and go away. Sometimes. Sometimes that does happen. But a lot of the times when you look underneath the farm for food stamps and you look underneath, there's other things going on that they need help with.
And so this idea of a one stop shop has existed for a very long time. Delivering on the promise of what a no wrong door or One-Stop shop or all doors are open, whatever language people prefer across states and counties that involve you all. And to do that, you have to think about governance. You have to look at policy.
You have to look at practices. You have to look at infrastructure. You have to look at human capital, and then you have to look at your partnerships. And this to me is core for this question that you ask, like what in government do differently? You've got to address all five of those domain areas, right? Policy, practice, infrastructure, human capital partnerships.
You got to move all five domains at the same time. And this is the hard part of transformation. They got to move them all with the value proposition of a whole family, whole child, whole person approach to delivering service. And so I used to always tell my state, do good policymaking and get out of my way. I know where to do right to go, how to get there, what to do.
And we did. I actually believe we did. We did a lot of those things was over. No, I was there 12 years was just a good amount of time to start to make transformation happen. You can't do it in three years. It takes seven, eight, nine years to do that. We had a conversation more recently, and, you know, we did a policy lab situations, behavioral health, and we said, how do we bring Medicaid, behavioral health, child welfare, juvenile justice, education to the table on how do we we right.
You can't blend funds because there are categorical reasons to keep them separate. But how do we weave all those in a way that best serves children and families? And a lot of that's about relationship and governance. You know, who's telling you to work together? Every department has its own mandate, its own fund sources, its own outcomes that they're accountable for.
But there are ways that you can build and create a more integral, aided system of care. I believe it can be done. I've done it. I did it at the local level, albeit I didn't do it at the state or the federal level. But you can do it. And one of the things that's important is you even have to go to attorneys and say, I am your clients.
This is where I want to get to help me get there. It was pretty effectively. We managed to do a lot as a result of that sort of problem solving approach. And that's a long answer to what you asked for.
No, but it really illuminates a lot of the pieces about a particularly, your point about transformation, taking, you know, seven, eight, maybe ten years. That's a long time when you have, you know, electoral politics and who changes at the top. And, so I guess I have a couple of questions to follow up. Do you think that the county level is where it needs to happen, or do you think that, it can happen at the state level in a way that can, you know, really, inform how counties can solve these?
I know a lot of services are delivered at the county level, so kind of what's the what's the location where this can be most effectively done?
I think each of the three tiers of government have a role to play. The federal government is where the bulk of the funding sits, right? So they have and Congress plays a role in that. The executive branch plays a role in that. And so I think it's important to have a again, over there at the federal level, like a few things.
Right. You're always going to have statutory environment and politics that are going to play into these things. You will never get everything you want, but having good policy specialists in these departments to get how to interpret the policies that are drafted in a way that facilitates a collaborative, integrated practice model, I think that is something that we can actually look for.
What often happens is everybody looks at it through their own siloed lens and the interpretation often varies. And it does not really. It's not intended towards collaborative practice. It's intended to ones who are going to do it this way. And so that is it would be nice, like if you had policy specialists who were brought into the importance of integration.
And even if you take something like confidentiality, privacy, hip, 42 CFR, all those things. Right, even over there, you've got one side of the House at HHS saying integrate, share information. These are the ways you can do it. And then on this side of the house, you have the Civil Rights Office of HHS, policing violations, data sharing, you know, and both are important.
But are they aligned? Is the question that I would pose. Right. At the state level, it's a little bit closer to the ground, right? States are supposed to know all of their communities how they're supposed to work. But again, the electoral politics that you talked about, the turnover is much greater. And those in our department are relationships are never quite let go.
All right. The secretaries may let go of it. But the department staff I know is really the role of the state is to make really good policy making and understand that the clients live in the counties and the cities in their jurisdictions, and how can they empower those local entities to do delivery? Now, there are two models of service delivery, right?
They're state administered, state supervised, which exists in many state or state supervised, county administered. And there's more empowerment of the local level for state supervised, county administered systems. Okay. It just inherently is Colorado, New York, Pennsylvania, state administered, state supervised. It's much more top down from the state and less autonomy at the local level. But then even with all of that means, those relationships that exist locally, you tend to go to the grocery store with the police chief, you know, or you're going to see your kids going to school with Parks and Rec or, you know, all those things.
They help build a level of trust and relationship building at the local level. And, honestly, I mean, I think local directors tend to stick around longer. You can stay there for a ten, 12, 15 years, a little unusual to get to 15, 20, but that's when transformation can happen. And so I'm a huge fan of local government and the ability of local government to deliver on this value proposition.
But all three have to have a role. And having good working relationships, you can't go rogue and say, I'm the county, I can go do whatever I want. You live it. You know you're working in the context of the state, so. Right.
Right. So in your experience, you know, thinking about the motivations, right. What to do this obviously, I think in terms of doing right by the families, better outcomes is paramount. But we know that, you know, funding matters and there's a finite amount of it. And it seems like in this space, there's kind of never enough for the need.
In your experience, did this save money by kind of a lot integrating. I mean, were there redundancies, would that were eliminated, or was it just kind of better outcomes without any change in spending?
Hard question. Because initially, whenever you're trying to transform, you need to actually put in more resources rather than less resources, because it's very hard to build a plan and fly it at the same time and see you actually need a cushion on the side, which is hard to get. And I did and have added there. And I think Covid changed a lot of those value propositions, you know, with the opportunity for virtual and hybrid and defining what that is.
And, you know, but my personal belief is if you're going to embark on transformative change, you've got to have a bolus of funds that you can support the transformation with and then but have a value proposition. It's almost like having a, you know, an account, a bank account, and you're drawing down up front, but then you're able to pay back into it 3 or 5 years because you're able to demonstrate the savings rate.
To your point, if outcomes are better, then you're going to save money, but you want to save money in the upfront, right? A lot of people ask me that, what's the value of doing this? If your people are now going to access more services because you're coordinating and collaborating better, and systems are designed in some ways to protect the dollars, right?
It's always a culture of scarcity. It's never a culture of abundance that drives our work together. And so that doesn't always happen. And it's very hard to find. But for a while there, there was a big conversation starter that was called, you know, social impact financing and the idea of social impact financing was that you would get these funds right.
It all started in England and through the prison system, where a bunch of businesses came together and said they were having so much turnover in their workforce. They talked to the national prison system, or was, I think in a, in a in a particular jurisdiction. Anyway, they said, we'll make these investment to job training, this, that and the other with the idea that there would be recidivism, we'd have stability of workforce.
And then when you see the savings on your end rate, you pay us back. Pay for success is what it was called. And then it became social impact financing. And now it's iteration is just performance based contracts like it's been through some changes. And so there for a while, there was this idea that an intermediary such as JP Morgan Chase or somebody would fund there would be an intermediary who, you know, and they did that at Rikers Island.
Mayor Bloomberg put some money forward. There were other initiatives like that across the country, and homelessness and justice populations were read that showed, like, the most promise housing, housing and homelessness and justice. And so if you think about that idea in government, and I always felt that it was a social impact or pay for success model for government, that was necessary, where you give a bolus of funds and the local or the state OMB or the county OMB was the financing entity, and the department would go and say, give me this amount of money.
Here are the outcomes that I would demonstrate. You get the funds and then based on your outcomes, right. It was almost like a shared investment model over time. And you could get to reinvest in your success and grow the program. I could never make that sales that Jennifer, but I would love to. Like if I could, that would be such a dream to actually see a transformation happen all the way through to the finish line.
So, you know, I, I think about this, the, the different separateness right turn often snaps. It's over here. Which apps if you take USD off, for example, snap sits in USDA, which sits in USDA farms sit in USDA. Do they actually talk to each other? And it's the same families they're serving hunger is hunger. The family that's experiencing hunger when a baby is born is also the family that's going to experience hunger when that six year old goes to school.
And so that's that. That's a perfect example of the separateness that exists because of regulations, because of funding sources. And if this is sort of a dream of mine, you did ask me to go ahead and say it, and I, you know, if if you had a threshold like 250% of poverty, you're going to get all these services, we're going to pay you, we're going to give you a, you know, but you have to have the social contract and you're going to go to work, you know, will support you.
You'll show wage day, you'll show career progression. We'll do these things with you. But you have to say, I'm willing, I'm going to participate. There will come a time in five years when that safety nets a trampoline, right? It has to be. You have to think about it. If you empower people, they will step up and do what's right.
And but that requires adequate childcare, that requires housing, that requires health care. Right. That requires that the mom is not worried about food. Right? I mean, I can't tell you how many times you have situations. Her mom is working two jobs, and she has no choice but to make really poor decisions about who watches her kids. And then bad things happen, and then we turn and blame mom for what happened.
And so that is about high quality child care. If you want people to go to work, you need that.
Jennifer Colamonico
So the USDA example you gave that's within the same agency, let alone that same family, may be seeing, you know, have services that are in other agencies, right and right being asked the same. Right.
Uma Ahluwalia
But anyway, I understand there are regulatory reasons, policy reasons why they sit the way they do. Congress wants farms to be recruited a certain way, which to be recruited to serve my, you know, so I get it, you know, snap and all the issues with accuracy and waste, fraud and abuse and the amount of time and money that gets spent, you know, with the inspector general and calculating and doing all these things like we create systems tend to create their own churn.
Yeah. And work. Right. Is there a streamlined way to think about this? Probably what we haven't decided.
Jennifer Colamonico
Not yet. Well, maybe that's the local government. I mean, just, you know, if there's very good reason for them to be individualized at the federal level in terms of funding, that doesn't mean that they have to remain siloed at the local level, which is maybe your point about could be.
Uma Ahluwalia
But that point on farms, you know, I think you can more easily integrate snap and work, and there's more of an attempt to do that. But Farms is in the school system, which is governed by Furbo, which is a fairly restrictive confidentiality. Privacy regulation brings it into schools. Public schools are their own entity, right. It's difficult for them to actually build partnerships.
But right now, the wave that's going on a school based health school, this mental child. What an opportunity, right? Community schools. What an opportunity to actually build a really robust primary prevention schools are the least threatening. So all manner of parents, including immigrant parents schools, are the least threatening access point for services for their child. What an amazing place.
And parents tend to get engaged in the education of their children because they want their kids to do well. So it's just a really it's a moment. We are in a in a historic moment to drive that partnership and in beautiful ways.
Jennifer Colamonico
I just I always feel like the elementary school especially is when parents are most engaged. And, you know, if there's obviously the entry way into the child, but the entry into the family and, you know, like as a, as a real opportunity as you describe.
Uma Ahluwalia
Absolutely.
Jennifer Colamonico
If you had a magic wand, what one thing would you fix to, get the this work on the right track?
Uma Ahluwalia
If I was Queen of the world.
Jennifer Colamonico
Yes. Queen with that magic wand. Absolutely.
Uma Ahluwalia
If I could, I would remove categorical eligibility the way it sits right now. And do a need based assessment that is marked to the living wage in that jurisdiction, and try to close the gap at the same time committing to improving the economic opportunities, the workforce and, you know, career progression sort of side of the house. So that ultimately, over some period of time, families could in fact, not need public support.
Right. And so then they're bouncing off the safety net only when they need a little bit of a boost, but they're actually able to live independently. That would be just it's a dream, right. Who wants to come hand out and say, give me those, give me those. Give no, nobody. Nobody wants to come and tell five different caseworkers.
My husband beats me. I cannot put food on the table. Right. I, I may be pregnant, but I have no health care. Like who? Who wants to do that? They would much rather be able to take care of their needs and their families on their own. So it's not sort of like my vision for a better world.
Jennifer Colamonico
I was interested in, in how that answer comes across, because it's always things that you wouldn't expect, necessarily, that could really make the biggest impact. And that's obviously why we interview people like you that understand those nuances. Is there anything else that you would add to the conversation that, you know, when people think about, really how to improve child health and child well-being and family well-being, is there anything else that you'd like to add that maybe people just too often don't understand?
Uma Ahluwalia
I think we have a very paternal approach to rescuing children, and not enough trust in the ability of families to respond to those needs. There are only very extreme situations where we actually need to remove children, and there are those situations and we should remove children are when they are at risk, their safety is at risk. But more often than not, what we see is child neglect, which is tied to poverty.
And so I do believe that there is an opportunity here for us to everybody wants to go rescue a child. You know, I heard this from somebody the other day. I'm doing work in a stoop that'll stay nameless, where a person said to me, you know, if every church would just adopt a child, it would all be okay.
But why are we assuming the mom and dad don't want to raise that child in the best possible way? And what is it we can do to strengthen Mom and Dad's ability, and to give them the tools to be the ones who can care for their children? And I really think that we need to. We're not here. We can't rescue children.
We have to rescue families. And we it's not our job. We need to equip families to rescue themselves. And so, you know, there are all these projects around the country called guaranteed basic income or universal basic income. And we serve 200 families here, 100 families there. And then we do all this research, but we know child tax credits, work earned income tax credits, work child support as IT poverty strategy works right.
We know these things work. We know where during Covid when people got a certain bolus of funds, children were not poor. And when they were not poor, they had better outcomes. When they had parents in their lives who were caring for them, they had better outcomes for the most part. Right? There were there are always outliers, and there are always going to be people who have uncontrolled anger issues or power and control issues of her children who hurt their, you know, their significant others.
All that being said, the vast majority of people do well when they have the resources to care for themselves and to care for their families. So the research and the evidence is there. How much more do we need to study this before we can say, okay, this is good policy, let's go do it. And is it going to cost in the short term?
To your point, yes, it's going to cost more in the short term, but it's going to yield more in the long term. Yes, it is. But who has the patience to wait ten years, 15 years, 20 years for the results to come in? And so the ACS were saying ACS two, if you have more harm now you see more health issues later in life.
But prevention is never a persuasive argument. We're always reactive and the way we respond in public systems. And so I wish it could be different.
Jennifer Colamonico
Well, maybe somebody listening to this will, find a way to make it so. But it is that patients we do not have patients for the long game here of investing in outcome that shows up again and again. But all the research shows it's there. So you make really great points. Well thank you. Thank you for making time.
Thank you for sharing your story and your perspective. And, we just we appreciate you and the work that you're doing. Thank you. This episode of Vital Viewpoints on Healthcare is brought to you by HMA Grant Prospector. Is your organization looking for behavioral health grant funding? HMA Grant prospector is your ultimate solution to streamline your grant search time and maximize your grant seeking success.
Get started today and unlock your organization's potential. For more information on the Grant prospector, visit HMAS Wealth management.com. Thank you for tuning in to another enlightening episode of HMA's Vital Viewpoints on Healthcare. We hope today's discussion has sparked new insights and perspectives. To learn more about our esteemed guests, please be sure to visit Healthmanagement.com/podcast. Until next time, stay informed, stay curious, and keep searching for the wisdom that will help to transform our healthcare landscape.
This podcast was produced by myself, Jennifer Colamonico along with Tiffany McKenzie in collaboration with our guests. The content is the property of Health Management Associates.
