An hour into the first day of the 2023 session, West Virginia senators had already suspended their own rules to fast-track several bills they deemed priorities. The very first bill had bipartisan support: a proposal to split the Department of Health and Human Resources into three different agencies.
“I do believe this is a good, incremental step,” said Sen. Robert Plymale, D-Wayne. “Something that we’ve needed for decades, quite honestly.”
The move to cleave DHHR was in direct opposition to the path suggested by an audit Governor Jim Justice had commissioned for DHHR last year. But lawmakers are moving forward anyway, after rejecting the audit as a failure lacking “any substantive plan for changing the organization.”
A week later, in the House Health and Human Resources Committee’s second meeting, delegates were discussing a nearly identical bill. It was the only piece of legislation on the agenda that day.
Former health committee chair Del. Matthew Rohrbach, R-Cabell, expressed how urgent and necessary he believes it is to split the agency.
“I would contend to you that an agency that is this large is too large for any individual to have their handle around,” he said to the other delegates. “After sitting in this committee for eight years, this is long overdue.”
Missing from that public discussion, however, were illustrations of what an ideal health agency would look like; one that, as committee vice-chair Del. Heather Tully, R-Nicholas, said, would “get the departments functional and serving those who are the most vulnerable within our ranks in our state.”
While the health issues the agency could address better are numerous, there are ways it could work with the state Legislature to protect West Virginians against disease and death. We break down what DHHR’s responsibilities are, who it is supposed to serve and where some problems have hampered progress.
What is DHHR supposed to be doing?
Versions of West Virginia’s health department are about as old as the state itself. In a state encyclopedia, John D. Law, a former DHHR communications officer, traced the agency’s origin back to the state’s first welfare laws, enacted in 1863.
Since 1989, when lawmakers created the modern version of DHHR, the department has been in charge of leading the state’s efforts to improve West Virginians’ health and wellbeing. West Virginia code underscores that the agency’s public health and human service departments are supposed “to prevent disease, injury, and disability whenever possible” and aid state residents who are “subject to the recurring misfortunes of life.”
That ranges from the Bureau for Behavioral Health, a department responsible for improving the mental wellbeing of West Virginians, to the Bureau for Medical Services, a group tasked with running the state’s Medicaid program.
State health departments across the country have similar responsibilities. According to experts, they can only accomplish these tasks with strong commitments from local lawmakers.
“You have to be wary about giving people an impossible task without the tools to make progress.”
Dr. Joshua Sharfstein, Johns Hopkins Bloomberg School of Public Health
Dr. Joshua Sharfstein, director of the American Health Initiative at the Johns Hopkins Bloomberg School of Public Health, served as the Maryland Department of Health and Mental Hygiene Secretary from 2011 to 2014. He said that while some drivers of disease are out of the control of health departments, West Virginians should be able to expect DHHR to tackle problems like overdose deaths, foster care mismanagement and infant mortality.
“It’s good for legislators to be concerned about the health of their constituents and to want an agency that has the primary job of improving the health of people in West Virginia,” he said.
Sharfstein noted that it is not unprecedented for a state to use different organizational models. Some states, like Alaska, have split their health departments into multiple organizations.
But regardless of the model, he believes that health department improvements happen by having good data collection and analysis, ambitious goals for improving health and realistic strategies for achieving those aims. To do that, legislators need to make sure that health departments have both the funding and personnel to carry those tasks out.
“You have to be wary about giving people an impossible task without the tools to make progress,” he said. “That’s not, in general, a recipe for success.”
Who is DHHR supposed to serve?
Like other health agencies, DHHR can only accomplish its goals of widespread health by focusing on what Tully underscored to the House Health and Human Resources Committee: helping West Virginians who are vulnerable.
To do that, the agency has a massive budget. This year, leaning heavily on federal funds earmarked for specific health projects, DHHR expects to have access to $7.7 billion — with only about $1.2 billion coming from state tax-payers. Even so, that $1.2 billion in state money represents about a quarter of Justice’s proposal for this year’s state budget.
The majority of the agency’s total budget, about $5.4 billion, is used to maintain West Virginia’s Medicaid program; that cost includes reimbursing insurance claims for over 600,000 residents.
About $240 million goes to running state health facilities, like Sharpe Hospital in Weston. $41 million goes to making sure parents follow child support rulings, and another $16 million goes to the Inspector General’s office, the group tasked with monitoring how the agency runs.
That leaves just about $2 billion for improving West Virginians’ health in other ways. Many of the dozens of DHHR programs that try to do this help residents in poverty, from the Supplemental Nutrition Assistance Program to the Low Income Home Energy Assistance Program.
Some of that money also funds programs like the Family Resource Network, a group of nonprofits throughout West Virginia counties tasked with supporting communities to meet their health needs.
“Whoever in DHHR decided to do FRN ought to get an award,” said Katrina Byers, the recently-retired Tyler County FRN director. Byers cited eye screenings, dental check-ups and food drives as some of the activities she was responsible for during her tenure with the nonprofit.
But the funding for these county programs is limited: each location receives an average of under $25,000 from the state, according to DHHR data.
Byers made just over $23,000 in 2021, her last full year working. She said if it wasn’t for her husband’s income, she couldn’t have done the job.
“I don’t know how FRNs do it that are from small counties like me,” Byers said.
Improving health disparities for West Virginians in minority racial and ethnic groups is another agency responsibility. While the state’s total infant mortality rate is alarming, the rate for Black babies is even higher. From 2017 to 2019, the infant death rate among Black West Virginians was nearly double that of all West Virginians.
DHHR has federal grants that are intended to specifically address racial health inequalities. But, according to a former employee, it is often difficult for different agency teams to coordinate these efforts.
For over two decades, Jessica Gamponia Wright worked in various public health roles at West Virginia health departments. In 2021, she retired as the director of the Division for Health Promotion and Chronic Disease at the Bureau for Public Health.
Gamponia Wright said that while she worked for DHHR, she often found it difficult for department teams to work together on projects, especially as they pertained to racial equity. She noted that her experiences may not reflect all DHHR employees and departments; because of little inter-agency communication at the department, she didn’t know how others felt.
“We hardly ever talked to the other bureaus,” Gamponia Wright said. “We’re so dadgum busy. We don’t have that time.”
What are some problems that have been overlooked by legislators?
In addition to the DHHR reorganization plan, the Legislature has advanced bills to address two issues that have received a lot of public attention: improving transparency and accountability in the state’s foster care system and reallocating child protective service workers to counties where they’re needed most.
Despite those bills, DHHR faces other problems that are hurting West Virginians’ health. Among them are funding the agency’s smaller programs; collecting and reporting health data; and hiring and retaining staff.
While state funds for Family Resource Networks are sparse, the program’s situation is common for small DHHR programs. Other agency initiatives, including those tasked with helping West Virginians with critical health problems, have lost funding over time.
In 2022, the state conducted an audit of the James “Tiger” Morton Catastrophic Illness Commission, a program designed to help West Virginians without insurance pay medical costs for expensive diseases like cancer.
The audit found that the commission provides a service that’s necessary for many West Virginians, but it doesn’t have enough money to be very effective. In 2011, the state allocated $700,000 for the program. By 2022, it got less than $19,000. That cut had huge impacts; according to the audit, multiple people died while waiting for commission assistance with their medical bills.
The agency’s tobacco prevention efforts have also seen losses in funding. In the mid-2000s, the state spent around $5 million a year to prevent West Virginians from smoking. In 2022, despite receiving hundreds of millions of dollars from the Tobacco Master Settlement in the 1990s, that number had dwindled to under $500,000. The American Lung Association cited that lack of funding as a problem in its critical West Virginia report, noting that 40% of the state’s high schoolers use tobacco products.
“We want to make sure West Virginia understands the importance of investing in prevention,” said Deborah Brown, the association’s chief mission officer. “We…believe the [Master Settlement] funds should be used for the health of our communities.”
Across the massive department, advocates have said a lack of high-quality health data is a problem that makes it hard to find well-informed solutions.
“The reports that have come out recently really need improvement and input from all the stakeholders,” said Margaret Chapman Pomponio, executive director of reproductive rights nonprofit WV FREE.
“It’s 2023. We should be at a point where we are taking time and creating strategies to get that data.”
kelli caseman, think kids
Even when reports are produced, they’re often lacking crucial information. In DHHR’s latest Fatality and Mortality Review Team Report, a document required by state code to review childhood deaths, the most recent infant mortality data by race was from 2017. It did not include rates, only overall numbers that tell researchers little about the problem’s severity.
Last year, Think Kids Executive Director Kelli Caseman started an initiative to assess how to address these types of gaps in West Virginia’s health data, especially among low-income, non-white and LGBTQ communities. Without that information, she believes DHHR and other state health leaders will overlook problems impacting minority groups.
“It’s 2023,” Caseman said. “We should be at a point where we are taking time and creating strategies to get that data.”
Staffing and retaining qualified personnel can also be an obstacle to executing projects. In its legislative budget presentation, DHHR reported that 24% of its positions are vacant — an increase from last year despite the department reducing the total number of positions.
According to Gamponia Wright, the vacancies are hard on existing employees, and the number of tasks assigned to each person in her department was overwhelming. And, because of convoluted hiring processes that often took months, it was difficult to find anyone in the department who could help.
“If you have to hire someone else, it takes forever to do that,” she said. “There’s a lot of processes and protocols that you have to follow.”
Even when employees can get through the hiring process, Gamponia Wright noted salaries as being a problem for many. Despite being government employees, she remembers many of the people she worked around having second jobs to make ends meet.
“It made me [think] ‘Are people who work for the Bureau for Public Health eligible for DHHR services themselves?’” she said.
Are these problems new? Will splitting the agency in three correct them?
Some of the issues, like data collection, have become more pressing issues in recent years. According to Caseman, in the mid-2000s, DHHR utilized federal funds to get accurate numbers on state health problems, like childhood asthma.
She said that when those federal funds went away, the Legislature often did not fill the gaps so the data collection would continue.
“If there's not federal funding to do it, then you have to find the funding on the state level to keep it up,” Caseman said. “And they just didn't.”
Gamponia Wright remembers the hiring process problems and the little interagency coordination as constants since her first days with DHHR, all the way back in the 1990s. Unless they’re addressed, she expects them to continue to hinder the agency from accomplishing its goals, regardless of organizational structure.
“There really needs to be time…to develop relationships to build trust,” she said. “And that’s hard to do when you have so many vacancies that you’re so overwhelmed.”
But as lawmakers work to cleave the agency into three separate ones — the Department of Health, the Department of Health Facilities and the Department of Human Services — Sharfstein, the Johns Hopkins professor, cautions that might not be a cure-all for the agency’s existing issues.
For him, DHHR’s setup is a secondary concern to addressing these foundational problems.
“I don't think splitting the agency, by itself, will make much of a difference without a commitment to provide the agency with the resources and the tools needed to be successful,” he said.