Christine Ferguson, Director, Rhode Island Department of Human Services
"Agree on some measures; publish what you have; perfect the measurements over time. We don't have time for perfect measurements. People like me are only in the positions we're in for a very short time." (Ms. Ferguson's Powerpoint presentation follows the text of her remarks.)
Implementing Rhode Island's Vision
Rhode Island has developed a vision, and people in leadership roles in and out of government have been able to craft and implement that vision. I'd like to give you some perspective on what we've done. In Rhode Island in 1995-96, we identified four outcomes for all children that we want to work toward:
- All children should enter school ready to learn.
- All children should leave school ready to lead productive lives.
- All children must be safe in their homes, communities, and schools.
- All children should live in families that are self-sufficient yet interdependent.
Depending on what kind of thinker you are, these outcomes are either really great or way too big. But what they did was to begin to narrow people who are very fragmented in their thinking and to broaden people who are narrow in their thinking. And so this consensus gave us a way of saying in any one instance that, "This is an initiative around one of these four things." In response to these outcomes, we were able to implement three programs critical to kids.
RIte Care. RIte Care is Rhode Island's comprehensive health care program for uninsured low-income families, enacted in 1993. This is our Medicaid managed care program in Rhode Island.
The Family Independence Act. The Family Independence Act, Rhode Island's welfare reform legislation, was enacted in 1996. This act included an entitlement to childcare. In other words, if someone comes to the door and meets the eligibility criteria, we have to provide them with the subsidy. There is no waiting because it is an entitlement.
Starting RIte. Starting RIte, Rhode Island's early education and childcare initiative, was enacted in 1998. It's not one piece of legislation, but, rather, lots of concepts combined, including quality health insurance for childcare providers and stepped up eligibility criteria for the entitlement. Under these provisions, a licensed childcare provider taking one subsidized kid for six months receives 100 percent free health insurance.
Our Expanded Investment in Kids Showed Results that Were Measurable and that Were Clearly Illustrated by One Chart
So our expectation was to begin to really invest in kids. One of the things we did with respect to our health insurance was to have incremental expansions every few years, and we're now up to coverage for adults at 185 percent of the poverty level and for kids at 250 percent. Those benefits are the Medicaid benefits that include Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). EPSDT benefits are wrapped around any private coverage that we subsidize. And we've been aggressive with respect to providing EPSDT coverage because it's connected to early education, early childhood kinds of issues. The result: improved primary care services, and a lot of other things.
But the reason I bring this up is this chart. The reason that we continue to have RIte Care in Rhode Island is this chart (slide 6). What this chart says is that those who got their insurance through Medicaid pre- and post-managed care, and those who got it pre- and post-RIte Care, virtually became the same in terms of the outcome of waiting eighteen months between children. That's important because it's an indicator of both maternal health and child health.
Usually I say the following things. What we found is that women who are low-income working poor and very poor families access health care in the same way and make the same decisions middle-income and upper-income women make when they have consistent medical services. I'm basing my conclusion on this and other data and on focus groups, and frankly on the observations of people I meet. What the data tell me is that when low-income women have a doctor or nurse practitioner or nurse midwife throughout pregnancy, they talk about contraceptives. When they deliver a baby in the emergency room, they don't, and probably none of you would either.
The Data Aren't Perfect, But, in Ten Years, I Could Be Dead
But my whole point is this: this is not peer review science. We've tried to publish some of these data in very strict journals and they wouldn't let it in because it's not drawn from large enough samples. So if you were pure you'd say to me, "But you can't draw those conclusions from this data," and I would say, "You're right, but you want to wait ten years to draw any of those conclusions and, guess what, ten years from now, I might be dead and this program might be dead." The reality is that when you're dealing with states or at the federal level, if you want to maintain a program or expand it, you have to be able to show either that nothing's gotten worse-because we guarantee the amount of money spent got worse and ideally that something's improved.
The Health Care Numbers and Charts Are Great, Although the Data Aren't Perfect
We've also been able to show adequacy of prenatal care. Again the gap gets closed. If you take health insurance status as a proxy for income, this indicator shows that the working poor and poor women are responding to health care in very encouraging ways.
And ultimately, we say we're number one in the country for health insurance coverage now. Only 6.9 percent of our people are uninsured, compared to everyone else. According to the GAO data, we're second, but it doesn't really matter because the drop in uninsured has been tremendous in the past few years. The change is what's important. Universal coverage is not so much the indicator, as what's happened as a result of it.
So, over the past eight years we've shown progressive improvements in health status with RIte Care. I always say to people you can't take this to a scientist and have them say to you that this is perfect data. It's not perfect data. We cobble it together from health department data and we have very credible researchers doing this at Brown University. It's outside evaluation. But it's not perfect and it's never going to be perfect. There's no way we could ever collect enough data to be perfect.
The Childcare Numbers Are Also Good
The childcare numbers are also good, but expenditures for childcare have increased 270 percent and the data are not that useful yet. It's too soon to use these data. They do not explain the financial impact of the childcare measures for legislators.
The Family Independence Act and Starting RIte pulled together a series of provisions related to health insurance for family childcare providers. We provide health insurance to licensed family childcare providers on an entitlement basis. We have a series of interventions in effect around quality and eligibility. We have wrap-around childcare services.
The number of kids served has increased by 100 percent since 1997 from 6,000 to 12,000, roughly. That's a lot because we've got a population of about one million. There are about 150,000 kids under age eighteen. Our childcare and after-school care goes up to age sixteen. So subsidies are available to kids up to age sixteen. Our childcare placements have increased by 27 percent in two years. Our childcare providers accepting DHS subsidies are up from 61 to 76 percent in two years. Availability has increased and we have almost 1,000 people who are receiving health insurance because they're family childcare providers or related to family childcare providers. But here's the rub: our childcare subsidy expenditures have increased by 270 percent since 1997, from 18.6 to 68.8 million dollars. And it's all state dollars. The legislature has flipped out on a number of occasions and the budget officer in the governor's officer has flipped out on more than a number of occasions.
Our rate of increase has been steady, luckily. So now I can give you all these great outcomes: who accepts subsidies, how many kids of which ages receive the subsidies and how that's increased over time, our investment, administration (what we've spent has gone down at the same time the program's increased), how much we pay for each slot, all of those things.
But you'll notice I could do all this with health care, too, but I never give those slides because they're not particularly interesting. All it is is claims and financial data mixed around a couple different ways, but it doesn't tell me anything about whether what kids are getting is helping in any way.
The Data I Need: Do Kids Know Their Letters and Numbers?
Knowing whether kids know their letters and numbers will help ensure the future of these programs. If the only thing you worried about with childcare was helping families go back to work, the data we have now is okay. But it doesn't tell me the important thing, the critical thing for the future of these programs whether kids enter school ready to learn. And I know this is a big issue but I want to know how many letters they know. I'm sorry, but that's important to me. It's important to the grandfathers that are on the finance committee, it's important to the governor that's what they value. Can you tell me, are the kids aggressive or not aggressive and all those things? Yeah, I want to know those things too, but I really want to know, do they know their numbers? Can they read? Do they have books?
I need to be able to say, oh yeah, childcare is going to continue to grow at a rate of 100 percent per year, and next year it's going to be 68 million dollars and we're going up to 74 million and yeah, I know you want a car tax repeal and I know you want capital gains and I know you're really worried about the expenditure in health care. But these kids are in a better position to be reading in the fourth grade and to be graduating from high school because they have this after-school enrichment program and these Head Start-like comprehensive services, because they have childcare.
And it's not a bad thing for these moms to be working. You don't have to feel guilty because you've put the moms back to work because the kids are doing well. That's what we need to tell them because the things that mobilize interest in children's issues are usually all the negatives, all the bad cases. You'll always be able to find a bad case of lead poisoning or a bad childcare situation or something that'll send somebody off in that direction. It's really hard to focus on the whole picture. We really ought to be fixing this in the context of what we already have, so don't set up a new program, please.
Based On Preliminary Data, the Governor and Legislature Have Postponed Tax Cuts and Kept Spending on Child And Health Care
What our governor and our legislature have done is to really decide to make the investment in children and families. But the last two years have been really hard because our childcare spiked up one year by 25 million dollars and next health care expenditures went up by 80 million dollars. And they're looking at me going, "Hello, we really want to do these tax cuts and you're really preventing us from doing them." And what we were able to say back to them, is, "These are not our decisions. These are your decisions. Here are the choices. There's progress that's been made here and you can cut it back but you've got to understand there's probably going to be some impact." They've chosen not to cut back. So we've gone through three years of them making the decision not to cut back.
And the only reason is because, on the childcare side, we took all those pretty charts but we didn't show them until after we showed them the health care charts and they just assumed the childcare charts were as impressive as the health care charts. But I can't keep that up for very long, because I really am honest. And when they ask that question about childcare I say "I don't have it, I can't tell you, it's too soon anyway. It's only been three years."
I Need You To Work Faster to Get the Data to Support Decision Making, Because the Backlash is Coming
So what I say in Rhode Island is, I know you guys are working real hard but it's not fast enough! Because I know I'm going to get these questions pretty soon. They're going to say, "It's been four years. Did the kids we helped four years ago enter kindergarten knowing their letters and their numbers? Can you tell me that, Christine?" And if I can't, and I say, "You know, well, there's a real disagreement over whether that's a good indicator of good childcare." They'll say to me, "So the answer is you don't know." And I'll say, "Yup." And they'll say, "So, how much money will it take before you do know." And I'll say, "Well, we really haven't decided. We can't decide whether it's knowing their letters or social adaptability." So take them all. Pick 100 indicators and put them all together. Come up with some way of providing decision-making kinds of information, because the backlash is coming.
This is not an unthinkable cycle. This is what happens every time. You pull people back to work. They focus on upper-income women who go back to work and they have all the mommy wars in the suburbs. And I'm one of the women who work and I know the mommy wars and now we get: children shouldn't be in childcare and women should stay home. But we're not willing to pay people to stay home, so what should we do?
We've always missed one part of the cycle. We've missed the opportunity to say, it's okay for some kids to be in childcare and it's probably not great for other kids it depends. But we like to have some basis to say those things and to have some sense that, even if they're not willing to say it, the reality is that the way to appeal to most of these people is: if you want a good work force twenty years from now you have to invest in these kids now in health care, education, and childcare.
And as long as money's the most important thing in the US and it is, that's what we value as a society, that's how we've evolved as long as that's true, then you've got to talk about it in that language. You've got to say, these are investments worth making, not because the kid's a better social citizen, but because the kid's a better worker. You may not like it but maybe you can also ensure the kid has better social skills at the same time. And the latter's beginning to reflect in workforce training. You've all been through the Myers-Briggs test and teamwork and systems thinking. All of that is really based on the things the kids learned in kindergarten you know, don't hit your friend over the head when he has the truck.
The Data I Need: A Closer Look
Track As Many Indicators As You Can. Understand That The People Who Make Decisions Have To Be Able To Justify Them To People Who Don't Care
So track as many indicators as you can. Understand that the people who make decisions have to be able to justify them to people who don't care about all the things that you care about, to the person in the street who is upset because they paid thirty percent of their income in taxes. They have to be able to demonstrate that their thirty percent went to something that really improves the future of the state.
It's Harder To Get Childcare Data Than Health Care Data
We have a lot of health care data to extrapolate from. A lot of people collect it. That's not true of early childhood data. We need to get data from childcare providers and schools. A critical issue for us is that we don't have a single student identifier. That makes it very difficult for us. And while we have three major health insurers to get data from, we have umpteen hundred childcare providers. That makes it more difficult.
We're working on all those things. People should be working on all these things at the state level. And regardless of which indicators you pick, you still have to be able to get the data once you pick them. So don't just focus on which indicators to pick. Once you tell me what you want, it's going to take me two years to figure out how to implement it if I'm lucky. So we need to figure out what we need to put into place in state government, regardless of what kinds of indicators you pick, to be able to get information back from a childcare provider, from a school.
The Kinds Of Comparisons We'll Need To Make: Subsidized Versus Non-Subsidized Kids
We also need to be able to compare subsidized kids' outcomes with non-subsidized kids' outcomes. We need to compare by income levels. Our reimbursement rate is very high. Three years ago it caused a thirty million dollar increase in one year. They want to know that what they're paying for is a return that is giving them something other than a babysitter, which is how many grandparents think of childcare. (We try to focus on early education, but they still call it daycare in many places.)
Have Faith! If It's Worth Fighting For, It's Worth Measuring!
All these things are really scary if you're frightened of ending up with comparisons that are not so great. But get them! You have to have some faith! If you believe the services are worth fighting for, you have to believe the supporting data are worth measuring. What will be shown will be used by you to improve the situation or to make a correction. If you don't believe they're worth measuring, then why are you fighting for them? So you have to be able to take the leap that what will be shown will be used by you to improve the situation or to make a correction. We may all be wrong. Maybe we should be back in caves. But those are kinds of value discussions that need to occur and they can't occur without some kind of reasonable information.
In Sum, They Need to Know: Are Poor Kids Reading Better, etc. (And ABCs ARE Important)
In sum, here's what they need to know. Are poor kids reading better? (And I use the word "poor" strategically, usually I say "working families," "the working poor" etc.) But the reality is, the guy sitting up there making the decision on the finance committee, the talk show radio host, the guy in his car sitting and listening to the talk show host, and most of your neighbors, think this way. And you have to be able to think this way in order to give them the information they need. You can change the way they think, but only gradually over time.
Do poor kids read better in the third grade? Are poor kids reading as well as suburban kids? Do poor kids know more when they go to school? Do they know as much as wealthier kids when they go to school? Those are the kinds of answers they want.
They're also interested in aggressive/nonaggressive, but frankly they are probably more interested in ABCs and 1-2-3-4. Maybe they don't care if we have smart kids that are mean. Maybe that's not worth it. Maybe the guy they work for is mean and maybe he's successful and they're not, so maybe meanness is also a value that we have. I don't know, but it's interesting to have the conversation. And if you have some data to talk about, it makes it even more interesting.
In Rhode Island, We're Looking at Everything We Have Access to, But It's Not Fast Enough. The Pressure For Tax Cuts Is Very Great
We're Looking At Everything We Can
In Rhode Island we have started the process of putting some questions into our SALT (School Accountability for Learning and Teaching) survey of schools, of looking at everything we have access to, and meeting my need of knowing whether the kids know their alphabet when they go to kindergarten and their need of making sure they're good kindergarten citizens and have good social skills and family situations. So we're getting there. I'm worried it's not fast enough.
The Pressure For Tax Cuts is Great
They want to see it fast. I don't know how much longer they'll continue to do this. The guy leading the finance committee, who is a great guy, has put off for one or two years his big centerpiece legislation, which is to give back property tax on cars. I don't understand the economics of that, but he's absolutely committed to it. He's delayed it for two years because of health and childcare expenditures! How many more years is he going to delay this? He can cut childcare and no one's going to think about it except the childcare providers. Health care's a different story because he can see the results and it makes him nervous. But childcare? There's always this back and forth, back and forth cycling.
Don't Let The Perfect Be The Enemy Of the Good
So agree on some measures. Don't think you're going be published in peer review articles. Most people don't read them anyway. Publish in magazines. And talk about the results and perfect them over time. Don't let the perfect be the enemy of the good. Do longitudinal studies to verify what we're learning. But we don't have the time for perfect measurements. The reality is, people like me are in the positions we're in for a short period of time. Six years is a short period of time, but for someone in my position, that's a long period of time. Legislators need answers. And they need information translated for them in a way they can use. Otherwise it all comes down to, how much of an increase did we give this program last year and isn't it time for another program to get it.
The Basic Thing I Need To Be Able To Say Is: "The Money Spent On Health And Childcare Means Less Money Spent Elsewhere"
The basic thing is, I want to be able to say that your investment in health insurance and early education results in less money spent to correct other problems. I want to be able to say because you have health insurance and early education, your schools systems have less money going to special education. If I can say that, we will never have those programs cut. OK? So, get to work! Keep plugging. I feel like I'm holding up a dam and there's a whole bunch of people behind it just waiting to tear down the dam. And I'm just waiting for the people behind me to get the work done so I can hold up the chart and say, "Here! Look! This is what happens! You don't want to come through here!"
If you can do that for me, I will be eternally grateful.
|FY99 Actual||FY00 CEC Estimate||FY01 Gov Rec Estimate||FY00 DHS 3/00 Estimate||FY01 DHS 3/00 Estimate|
Starting Right included above:
Not included above:
Child care disregard is based on the number and ge of the children. Children under age 2, maximum of $200 per month; other children up to $175 per month. No total maximum. Client must provide proof of expenses. Child care providers can be unregulated.
Charts depict the growth in licensed child care placements in Rhode Island - subsidized and unsubsidized since Starting Right.
This chart describes growth in individual licensed placements - previous chart shows the increase in licensed providers
Outcome: provider rate increases, health care subsidies for providers, employees, development grants have been effective in building the system.
Percent growth from 1999
DHS Center: 33.2%
DCYF Center: 26.%
DHS family : 57.9%
DCYF family: 24%
This chart shows growth in number of licensed providers (not placements). Also shows growth in number of providers who accept DHS children
Outcome: Starting Right has built more capacity for subsidized children and non- subsidized children
Total certified/licensed equal 1404: 988 certified family CC homes + 416 licensed center based programs
Accept DHS subsidy: 740 certified family CC homes + 317 licensed center-based programs
Since Feb. 1999 reimbursement rate increases took effect, 26.l4% of providers have increased the Number of slots within their programs that are available to DHS children-so since Starting Right Impact-increased number of programs and increased number of slots within programs