Big things seem to happen on Wednesdays. A week ago Wednesday, we opened up a brand new innovative Health Commons in Rio Arriba County. A week from Wednesday, the Rio Arriba Community Health Council is meeting to untangle a Gordian knot caused by conflicting regulations attached to state and federal funding streams. If we can solve the puzzle, we can form new alliances and relationships…bringing America closer to single payer health care…permanently.

I am the Director of Health and Human Services for Rio Arriba County. Instead of meeting with a select group of providers behind closed doors to negotiate an end to our community’s complete lack of mental health services, I am inviting the public to participate in the discussion. I hope to accomplish a threefold goal: 1) to help the community at large to recognize and untangle the complexity of our health care non-system; 2) to develop consensus and support for meaningful reform so that we can increase access to mental health services in a community that has been severely impacted by epidemic levels of PTSD and substance abuse; and 3) to develop a permanent sense of confidence that our community can change the world around us and that government can indeed provide quality care.

Community coalitions (in this case, our health council) are critical to our march toward single payer and will help to change facts on the ground, thereby turning Medicare for All into a real possibility.

Like all true Gordian knots, our conundrum has many strands. Both federal and state funding streams actually incentivize providers to create rather than solve problems. Unfortunately, each strand is also attached to a set of acronyms. I will try to avoid lingo or else to explain terms as I go along.

Last year, the only community mental health center in Rio Arriba closed down. We are approximately the same geographic size as Connecticut and Rhode Island combined, and we have some of the highest drug overdose death rates in the nation. The drug problem is heavily concentrated in the area surrounding Espanola, our “urban metropolis” of 9,000 people. Many of the families living in Espanola originated in farming villages but moved south for (low-paying) wage jobs. While we are a small town, we suffer from many of the same problems as ghettos in large cities and for some of the same reasons. A farming population dependent on barter and extended families has become isolated and ghettoized in a semi-urban environment. Widespread culture shock (or soul wounding) ensues. Confidence and a sense of self-control over personal environment is the cure.

The state of New Mexico farmed out management of all behavioral health services to for-profit managed care conglomerates five or six years ago, just before Governor Bill Richardson embarked on his Presidential run. Now the state is implementing a new sub-layer of management, referred to as a Core Service Agency, under the managed care entity. Each Core Service Agency is responsible for ensuring that clients in a specific Judicial District have access to mental health, substance abuse and medical care. They are also to provide a limited form of case management termed “Core Community Support Services” or CCSS. CCSS are capped for each client and do not include transportation, making the service inadequate for an extremely challenged rural community. To further complicate the problem, our Judicial District to be served by a single Core Service agency covers three extremely diverse counties: Rio Arriba, Los Alamos and Santa Fe. Los Alamos and Santa Fe Counties are the two wealthiest counties in NM and Los Alamos boasts the highest concentration of PhDs in the United States. Both counties have large Anglo populations. Rio Arriba is one of the poorest counties in New Mexico with a primarily rural, Native American and Hispanic agrarian population. School drop out rates are high. IThere is no single agency capable of meeting the cultural needs of all three counties.

(The state is actually creating two Core Service Agencies per judicial district: one for adults and one for children but we’ll ignore this additional complication for the sake of trying to make the problem understandable.)

As Director of Health and Human Services of Rio Arriba County, I have little influence over state policy. I will not improve health care for our residents by harping on the obvious inadequacies of the Core Service Agency concept. I can do more good by working with state agencies to try find a way to provide quality care within the constraints of their system. If we do this, the local system of care we create will remain in place long after the state’s managed care juggernaut either succeeds or collapses or is replaced by a new Governor with a new personal enhancement plan. communities need to look at the HCR bill as an opportunity. The system of care we create as a result of this bill, and the hundreds of other systems of care created by community coalitions across America will form the foundation of the true and meaningful health care reform still to come.

Meanwhile, back to the knot. Optum, the Insurance Company that is managing state behavioral health dollars, put out a request for proposals and selected a New Mexico non-profit corporation as the Core Service Agency for our judicial district. Presbyterian Medical Services [(PMS) not to be confused with Presbyterian Hospital Systems (PHS), the statewide non-profit that runs our local hospital, and nor, for that matter, with the Presbyterian Church] is our new Core Service Agency. They set up shop and began providing mental health services in Espanola in January.

At that time, at the request of members of our health council, PMS began providing intensive therapy services free of charge to very high risk students at the Carlos Vigil Middle School. Juvenile Probation reported an immediate and sudden drop off in referrals from the school, so we know that availability of appropriate services for highest risk individuals works.

Okay, here’s where it starts to get complicated. Federal and state funding streams for behavioral health services are paid at different rates. The state rate does not meet the actual cost of service delivery which is why our previous community mental health center limped along providing substandard and sporadic service for years before it finally keeled over and died. Federal rates are much higher, but in order to bill at those rates, an entity must be a Federally Qualified Health Center or FQHC. (People who don’t dabble in acronyms usually refer to them as public clinics.) PMS, which is a Federally Qualified Health Center in Santa Fe and Los Alamos (along with other New Mexico) Counties, applied to the Health Resources Services Administration (HRSA) to extend its FQHC status to Rio Arriba without informing the local health council or other local partners. The existing Federally Qualified Health Center in Espanola objected strenuously when they learned of the move. The other two FQHC’s also opposed the move and have requested that the County weigh in with the Feds to prevent the expansion.

Current long-standing federal regulations governing FQHC’s strongly incentivize clinics to depress the number of health professionals in low income communities while penalizing them for increasing access. Communities are scored according to the ratio of physicians to population. If the ratio is extremely low (meaning that residents lack adequate access to a physician’s services) then the Federal Government will repay medical school loans for doctors working for an FQHC in that community. It becomes possible for rural clinics to attract and retain medical professionals without having to pay prohibitive big city prices. However, if they attract enough doctors to serve the community effectively, they lose the ability to offer loan repayment, making it much harder to compete in the future.

Rio Arriba’s medical care system is composed of three Federally Qualified Health Centers (several of whom have multiple sites), and one hospital, and functions very well. We need to find a way to build up mental health services but we can’t do anything that will harm medical care. Obviously, we can’t untie the knot unless either PMS is willing to operate at a loss for a period of time in order to build relationships and trust in our community, or the state of New Mexico or the Federal Government (or both) applies a new, flexible interpretation to their regulations or all of the above. And the state and feds are unlikely to develop newfound flexibility unless we as a community can achieve consensus around a proposed solution.

This is our charge next Wednesday. We are going to bring all the stakeholders together in one room and attempt to forge consensus around an as-of-yet undefined solution. I don’t know what the solution is. But I do know that each stakeholder will have to give up something in order to get there.

I am not going to invite everyone into the room so we can have a free-for-all. A lot of work is taking place to make sure we get to a solution. I am on the phone with all the stakeholders finding out what each truly needs to operate in a new environment and what each can give up. Discussion will be directed towards reaching a solution. I prefer a Japanese style of negotiation termed haraage, or “stomach art.” In Japan, the stomach or gut is the seat of the emotions. Pressure is used only as a last resort and only with lone hold-outs once consensus has been achieved by nearly everyone. Ideally, at the end of the process the community conducts an about face on an issue (such as whether the Japanese Emperor should surrender to the Americans after WWII) without any dissent and without anyone losing face. Hold-outs are exiled to far flung rice farms.

The trick is to help stakeholders figure out in advance what they can afford to give up in order to potentially gain much, much more. The trick is to help them develop confidence in new, unestablished relationships without a history of past cooperation on which to rely.

The trick is to build faith in community, faith in ourselves, faith in one another and faith that Yes We Can!

More on this topic after our Gordian Knot untying work session has taken place.

Cross-posted from Blogistan Polytechnic Institute