Let’s say that you were working in a state, county or city with a homeless person who had bipolar disorder, type 2 diabetes and multiple incidents of hospitalization. Obviously, there’s a lot to be done for that person from a variety of agencies in order to provide housing, address mental health needs, deal with the chronic health condition and so on. Wouldn’t it be good if the various agencies and departments involved could easily share information about the client?
Consider the advantages for the person. For one thing, he or she would no longer have to repeat intimate information to a series of different case workers. When the agencies are all able to see the same information about the same patient, they can coordinate to build upon the care others are providing, instead of starting from scratch every time.
From a state’s point of view, the efficiencies in service delivery from sharing data are obvious. They would save time and money by re-using the same data instead of gathering and storing it over and over again. In addition, it would help the state avoid duplication of services.
So, why not share away? One reason is concerns about privacy and confidentiality.
Tracy Wareing, the Executive Director of the American Public Human Services Association, is dubious about this proposition. She says that many managers are challenging the presumption that confidentiality is an inescapable obstacle.
“There is a lot of leeway under current law that allows for appropriate sharing of information. Many government employees have changed their focus from 'why is it we can’t share information?' to 'why is it that we can and should?'"
Wareing’s belief that privacy and confidentiality need not stand in the way of the efficiencies of data sharing have been borne out in Montgomery County, Md., a diverse community with a little over a million residents. In 1996, the county integrated all of its health and human services. But the merger didn’t automatically make data sharing possible. A variety of privacy-related federal and state laws seemed to stand in the way.
Solutions were possible thanks to cooperation from the Montgomery County attorney’s office. “They told us, ‘you are our client,’” said Uma Ahluwalia, director of the county’s department of health and human services. “'We have to get you what you need,’ instead of saying ‘you can’t do what you want.’”
It took over a year for the county to figure out how to resolve the struggle between the agency’s needs and statutes. Four clear criteria were most important. If they are followed, the county determined data sharing was far easier:
1) The use of the data has to be for purposes of treatment.
2) The use of data has to be limited to what is necessary for treatment at the time and nothing more.
3) Only specific people in an individual agency can access the data.
4) No one involved should be asked to go outside his or her own rules of professional ethics.
With those principles in place, Montgomery County told the agencies in health and human services that if they didn’t want their information shared, they would have to opt out. “That’s an extra step they have to take,” said Ahluwalia. “And by doing it that way, the majority of people go along.”
Marijuana legalization in Colorado is producing massive headaches for neighboring states. They feel it’s necessary to provide more law enforcement personnel to combat the trafficking of marijuana from Colorado into their states, where the possession and sale of pot is still illegal. Legislators in Nebraska, for example, were so concerned that they called for an interim legislative study to look at increases in workload for Nebraska’s county sheriffs, state troopers and courts.
Shawn Hebbert, Grant County Sheriff, told the Nebraska judiciary committee in a recent hearing that many problems have accompanied Colorado’s legalization, including an increase in driving under the influence of marijuana. "Colorado's problems are our problems, except we don't get any tax revenue to help pay for them," he said.
Programs with potential for serving the public often don’t live up to their expectations. Sometimes this is a result of ineffective implementation. Sometimes people just expect too much from the programs. But with surprising frequency, a shortfall in results comes about because legislatures don’t provide sufficient funding to enable programs to deliver.
We saw a clear example of this in the debate that occurred over historic preservation tax credits in the Indiana Interim Committee on Fiscal Policy. The overall cap on the money available for the tax credit is less than half a million dollars. (By contrast, the cap on what's available in Iowa is $13.5 million.) The consequence of this very low cap is a very long wait to collect. The backlog of approved projects currently extends to 2024.
"It produces frustration," said William Sheldrake, a former Indiana budget official who is president of Policy Analytics, which has studied the issue. "A delay of about a decade means that the credit has no real effectiveness in terms of incentivizing current investment."
On Nov. 11, NPR's Steve Inskeep ran a segment about a long-term study of a cash support program for mothers, which was administered by the states between 1911 and 1935. It was dubbed the Mother’s Pension Program, and it provided a subsidy to families with young children but without an adult male around earning money to support the family. Although the memory of the program itself may be buried in history, the results disclosed in the study are worth considering today.
Researchers at Brown University looked closely at histories of the children from both the group receiving support and a natural control group of mothers who weren’t. They found that the children of women who received a modest amount of cash for three years were better off throughout their lives -- they stayed in school longer, earned about 15 percent more as adults and lived a year longer, on average.
This kind of evaluation takes place relatively infrequently, which is unfortunate. Inskeep talked about that issue, too: "The reality is when we debate public policy, we often have no idea what we're talking about. Even members of Congress may sometimes have no idea,” he explained. “We do not analyze public policy with anywhere close to the scientific rigor with which we analyze the efficacy of drugs or the safety of cars. We don't study it in that way."
“One of the great mistakes is to judge policies and programs by their intentions rather than their results.” -- Milton Friedman
How can the health departments persuade resistant patients in need of mental health care to accept necessary services in an inpatient facility? It’s not easy, but there may be a strong option, according to an overview of state commitment procedures provided to a mental health study committee in Virginia. The document reports that, "Some states have addressed [the issue] by implementing different standards for inpatient and outpatient treatment."
The idea is to shift involuntary mental health care treatment from inpatient to outpatient settings. John Snook, deputy director, and Katheryn Cohen, legislative and policy council, of the Treatment Advocacy Center, told Virginia lawmakers that states that implemented this approach -- including Massachusetts, New York, Ohio and Tennessee -- all reported that their new systems were more efficient, freed up voluntary services and reduced mental health service costs.
We’ve long been concerned about the lack of capacity many governments have for appropriate oversight. Here’s one case that has pretty much rendered a critical commission in South Carolina toothless, according to an article in The State.
South Carolina’s Ethics Commission is now asking for more staff members for the purpose of auditing financial disclosures that public officials and candidates file. As things stand, the State Ethics Commission only follows up on potential improprieties when it’s been jostled by a complaint -- and it’s got a long backlog of complaints. In the current budget process, the commission is asking for enough cash to actually look at the fiscal disclosures that are filed and proactively seek out ethics violations. Sounds like a good idea to us -- if South Carolina really cares about enforcing its ethics laws.