Outgoing Arkansas DHS Secretary Cindy Gillespie walks alongside her successor, Mark White, at the Fall Food & Craft Fair on Oct. 7, her final day on the job. The fair near DHS’ downtown Little Rock headquarters featured crafts made by DHS clients with intellectual and developmental disabilities. (Stephen Thornton/Arkansas Department of Human Services)
Cindy Gillespie’s last day as the secretary of the Arkansas Department of Human Services was Friday. Advocate Deputy Editor Hunter Field had a brief conversation with Gillespie and her successor, Mark White.
Gillespie, whose annual salary was roughly $287,o00, is leaving after more than six years at the helm of Arkansas’ largest state agency to spend more time with her family in her native Georgia.
During her time at DHS, Gillespie has overseen significant changes to the state’s Medicaid programs, an overhauling of the juvenile justice system and changes to Arkansas’ behavioral health infrastructure among other programs.
DHS’ current annual budget is more than $10.6 billion, and the agency includes a multitude of divisions, including Aging, Adult, & Behavioral Health Services; Child Care & Early Childhood Education; Children & Family Services; County Operations; Developmental Disabilities Services; Medical Services; Provider Services & Quality Assurance; and Youth Services
White, who was previously chief of staff and chief legislative and intergovernmental affairs officer, was sworn in on Monday.
Some answers have been edited slightly for clarity.
What were the biggest issues and accomplishments at DHS during the six-and-a-half years that you were in charge?
Gillespie: It’s been quite a six-and-a-half years. There’s a lot of very specific things we can talk about, but as I’m leaving, what hits me the most is from a big-picture level. When I came here, we were an agency — really great people, a lot of really great people, who were having trouble getting their jobs done. And they were very frustrated as was the outside world, but the folks inside were also extremely frustrated. We were 10 very separate divisions operating, as Mark says it well, operating under one roof, but we really were not an agency. We weren’t DHS. Over the years, starting with restructurings we did, but a lot of work with everyone together on: How do we focus on the client? How do we focus our programs together on a client? How do we work together across this agency and putting in place technology to help us do that? Working with everyone across divisions and operations on how they operate together. Just completely reworking the way we did our business in many cases. We were headed towards what we called internally One DHS, so we can serve people better. We were feeling like we made a big difference as an agency, and the pandemic hit.
I guess when I look back on the last six and a half years, a third of it was spent with us in a pandemic. And I think for me what I see more than anything is that when that pandemic hit the work we’d done the first four years allowed us as an agency to not be off in our silos but instead to all come together and on a dime turn as a group and keep services going. The mission across this agency is huge.
So from where I sat watching what was going on with our folks, I was blown away. Not just by the way they kept their day-to-day services going, made sure that people had health care, made sure that they had food. The facilities we run, having to lock those down, keep people safe, do what they had to do. Making sure that children who were in a dangerous situation at home, make sure we could still get in there. But what I also saw when I look back and think about it, the way everyone reacted to come together across DHS to figure out what to do.
We have folks who we serve, who providers [provide] services, and we pay providers to go into the homes of the elderly and disabled to provide services in their homes. All of the sudden when this hit and everyone was losing staff all over the place and providers were really struggling, how would we know that folks were safe? So other parts of DHS provided hundreds of workers who got on the phone and made calls to over 10,000 folks a week just to check on them and see: “Has your provider shown up? Do you need anything? Do you have food? Are you getting your services?” That was what we call One DHS. It wasn’t a question.
Again and again, the things that needed to happen, it was just: “Alright, who can do it?” And everyone supported everyone and we kept going.
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I leave here, more than anything, really blown away by the people inside this agency. What they do everyday and how they do it. During the pandemic, it took a lot of courage for them to keep coming into the offices out there in all the counties. It took a lot of courage for them to keep coming to work in our facilities, and it took a lot of courage for our child care workers to keep going into homes. For our folks to do what they did, and they just did it. More than anything, I walk out of here really amazed at the people of DHS.
How do you feel about the state of Medicaid expansion and how it has changed over your time here?
Gillespie: I’m super excited about where it is now, where we’re going. I’ve said to Mark many times, “Please when you get the Life 360 homes up and going, that first one, please send me pictures, please let me know.” I am more excited about the fact that, not just for Medicaid expansion but across all Medicaid programs now, we are about to do home visiting for high risk pregnancies. For the Medicaid expansion population, where a third of our babies are born, the way we’re going to do that high-risk home visiting is not just while the mother is pregnant, but it will continue up to two years after that child is born. That, I personally believe, is going to make such a huge difference in what we look like right now in our state in terms of both the health and the development of children, infants and that very, very young stage. This for us will be revolutionary. It all came about doing it across all of Medicaid because we started down that road with the expansion population. That is where so many young moms are. That I’m super excited about.
Life360 is a new component of Arkansas’ Medicaid expansion program that allows DHS to contract with hospitals to provide “intensive,” community-based care coordination for three categories of at-risk enrollees:
• Women with high-risk pregnancies
• Rural residents with severe mental illness or substance abuse disorders
• At-risk young adults, including foster kids and formerly incarcerated youths
I’m moving to a rural area in Georgia. I come from a family that has always lived in rural areas for generations. So I’m super excited about the rural Life 360 homes, to finally have acute crisis unit for someone who is actually having a mental health breakdown in a rural area, a place for them to go and get services. It doesn’t exist because the population is so small. So you can’t have full-time mental health facilities there, but we’re going to be able to do that now, which is really amazing. I think that’s going to make a difference. Working with social determinants of health is going to make a difference.
I’m particularly excited because this version of expansion has been going since 2014. We have seen through the expansion an improvement in health care access for that population, but we haven’t seen the level of improvement in health care outcomes you would expect to see from taking a population from uninsured to insured for seven years. So actually putting in baseline metrics and tracking it to see now what is going to happen when you really focus on it and tell the carriers they have to improve health or there will be financial penalties. That’s a different way of looking at insurance, and I’m excited to see what that’s going to do.
I love where ARHome is because it’s all at once hitting areas where we know we’re weak in, like infant and maternal health. It’s also hitting rural health, and it’s also hitting on alright, we cover people to help them get healthier, so let’s actually drive health outcomes. I think it’s a very exciting demo that is now underway here. I’ll be watching.
Arkansas created a unique program following the 2010 passage of the Affordable Care Act, commonly known as Obamacare.
The federal health law allowed states to expand Medicaid to cover individuals whose incomes exceed the federal poverty level.
For that population, Arkansas created a program that uses Medicaid dollars to purchase private health insurance for eligible non-disabled adults between the ages of 19-64 with incomes up to 138% of the federal poverty level ($18,754 for an individual and $38,295 for a family of four).
The program has gone through various iterations, including the private option, Arkansas Works and ARHOME.
Arkansas is one of 39 states to expand Medicaid, but it is the only one using this experimental approach to incorporate the commercial health insurance market, making comparisons hard.
After these years, as a policy person, how do you feel about this great private-option experiment?
Gillespie: I think it has definitely done a lot of what Arkansas set out to do when it was created. Part of the reason to do it was to create, in addition to obviously providing health care coverage, was to create a better financial underpinning for the state’s medical structure, including and in particular the rural areas. Rural areas, and you’ve seen this since you’ve been following it, the closure of hospitals in all the states around us in the rural areas and the lack of closures in Arkansas are directly attributable to the funding that flows into those areas because of the way Arkansas did its expansion. I truly do believe that. Most of the people served in that medical community in the rural areas are either on Medicaid or Medicare. Infusing the commercial rates on the Medicaid patients has really made a difference in terms of maintaining access. So from that standpoint, I think it has been truly a success.
It is different working with insurance versus working with fee for service or managed care. That’s why I’m very excited about his demo that’s underway now, which is how do you get insurance to actually focus on driving health outcomes? It is a different way to look at moving populations through insurance. So that I think really will be exciting because it allows you to maintain these higher payments, but at the same time begin to add on some things that will therefore mean that the companies will have to have more engagement with their clients and more engagement in those communities, populations to drive health outcomes. Government is not micromanaging how they get there, as we often do. We’re just saying ‘Get there.’ I will say our partners really do want to get there. I mean they serve Arkansans and they want to make this happen. I think it’s a positive partnership, but it’s going to be fun to watch.
Thinking toward the future of the program with a new governor coming in, new legislators, do you have any sense for the future of the program? Would you have any advice for someone coming in and trying to scale it back or get rid of it?
Gillespie: I’ll start with advice, and then let Mark tell you what he thinks about the future, because he is the future. What I have seen with our Legislature is a genuine commitment, whatever anyone thinks about the program, our legislators are genuinely committed to the health of the citizens of Arkansas, particularly to the health of the children and the families. I think now that ARHome is focused now that Medicaid expansion is really focused on driving improvements to infant and maternal health, there is huge support for that. You talk to them and it hurts them that we rank badly here. It’s not about the ranking; it’s about the fact that there are other states in our country that are in worse shape than we are and yet our infant and maternal mortality rate is higher. That bothers them in their souls, and they realize that this is a program that can help them make that happen. The other component of it is focusing on health outcomes. They want know that if they’re spending money they’re getting a result. So, they want obviously the rural hospitals and rural health care to stay strong and get stronger, but they also want to see people get healthier. They want those outcomes. So from that perspective as we went through this last legislative cycle, what I saw was many legislators who, whether or not they support the concept of Medicaid expansion, truly support deeply the idea of doing more to get a healthier population and to improve our health outcomes for babies.
White: In my conversations with legislators, they have increasingly recognized I think the case that was made from our side all these years, which is: the Affordable Care Act imposed on states a series of tradeoffs. They were taking some things with one hand and giving some things with the other hand. The design around this system was to see what is the best deal for Arkansas and what would be the best for our future. And legislators have increasingly recognized the extent of which Medicaid expansion has helped protect and preserve our health care infrastructure and capacity in this state. And they certainly do not want to do anything that is going to put that at risk. Going forward, they do want to see sustainability. They want to see accountability for outcomes. That’s precisely where we’re working around Life 360 homes to help expand that and to build on what we’ve accomplished so far but to illustrate more health outcomes to show the benefit of this coverage for Arkansans.
Mark, do you have any concerns about the future of the program? That it would be in any kind of danger?
White: At the end of the day, it’s always a decision for the Legislature, and the Legislature changes every two years as members leave and new members come in. I think we have a solid case to make to the Legislature for what would make the most sense for strengthening Arkansas’ health care system. I think they’re receptive to that argument and we’ll continue to work with them to make the best choices that give us the most advantage and help build up that infrastructure.
Any regrets or decisions you wish you could have back?
Gillespie: You always have regrets, you always have things you wish you could do differently. You always have things you wish you’d done faster and things you wish you’d done slower. I could sit and list those for hours. I won’t do that. It’s funny I’m happy right now to be going because I want to go be with my mom and sister. My biggest regret is probably there are some things that I wish I had the time to finish up here. There are things we’re in the middle of. I have driven poor Mark crazy about those. There are improvements that we are working rapidly to make to our behavioral health system. Gaps we’re working quickly to fill in that system. Services we need to get on the ground here in the state. Everybody is moving fast to do it. For me, that’s probably my regret today: that I can’t stay to help drive that. But I’m also very comfortable that everyone here is so committed to getting this stuff done and in place as fast as we can. Complex cases, youths and adults who really are those most difficult to serve, that’s a big area of focus right now. I wish we had been able to focus faster on that one.
We talked mostly about Medicaid, are there any other programs under DHS that you wanted to mention that saw a lot of developments during your time as secretary?
Gillespie: So many areas have just done such a phenomenal job improving what they do and how they serve folks. Anyone who spends five minutes with me will usually hear me talk about how I’m so proud of our juvenile justice team, our Division of Youth Services, who along with our mental health folks and others here, have really changed the way we treat kids that the courts order into our custody. It is a completely different program now: The treatment they receive, the assessments that are done, the way we follow up with them when they leave. The whole program is transformed and it is really now about individually assessing that child, getting them their treatment and making sure they receive it and staying in touch with them when they leave and putting services in their home so they don’t come back to us or wind up in an adult prison. That’s a huge change.
Our child welfare workforce probably has the biggest challenges, as you know. They have been doing incredible work over the last few years to really focus on safety. I’m really proud of the work they’re doing to focus on prevention. If you can get into a home early enough before it’s not safe for a child to be in that home, put services in that home, stay closely monitoring what’s going on but try not to disrupt that family and put that child through the trauma. That’s a whole area they’re really focused on. Their ideas to try something nobody has tried before, a teaming approach. Instead of having one child welfare worker on a case or investigation, they team and have two, not just for safety but to have the workload make more sense. They’re doing some amazing things here, just amazing people.
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Long-term care, an incredible area. I’ll say the nurses there, I’m incredibly proud of what they did during the pandemic. We actually led the state when they came down and said “OK, now we know what needs to be done to prevent COVID from spreading, so everyone will start these new inspections to make sure that all the long-term care facilities, everyone is doing what needs to be done and properly trained and adhering.” We led the nation in that. Very, very proud of them for how quickly they implemented and did that.
I always feel like I’m leaving folks out because I am because there’s so much here. We grew child-care centers during the pandemic. Who grew child-care centers? We came out of the pandemic with more child-care centers than we did into it. We were just recognized nationally leading in terms of quality of child-care in the nation. That’s pretty great right? Just amazing. At the end of the day, there’s just some really amazing people who work here. I’m going to miss them so much. That’s the hard part.
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