Iowa Department of Human Services Director Jerry Foxhoven “does not have enough votes to be confirmed,” Democratic State Senator Pam Jochum told Bleeding Heartland in a March 4 telephone interview. “He’s in trouble” largely due to concerns over the state’s handling of Medicaid privatization, she explained.

Governor Kim Reynolds named Foxhoven to lead the huge state agency last June. Gubernatorial nominees need a two-thirds vote in the Iowa Senate (at least 34 out of 50 members) to be confirmed, and Republicans currently hold 29 seats. Democrats have used their power to block nominees sparingly since Terry Branstad became governor in 2011, unanimously confirming hundreds of appointees and opposing one or two per year.

At a March 3 legislative forum in Dubuque, Jochum mentioned Foxhoven’s nomination was in jeopardy (hat tip to Twitter user @nwfisch). During our interview the following day, Jochum said the DHS director did not receive any Democratic votes in the Senate’s Human Resources Committee, which recommended Foxhoven for confirmation last week.

Last June, Foxhoven told the Des Moines Register he would focus on improving morale among DHS staff. As for Medicaid,

Foxhoven said he’s open to suggestions on how to improve the privately run system.

But, he said, “I don’t see it going away, to be honest with you.” […]

He expressed optimism some problems with the privately run system will soon be smoothed out.

A leading critic of Medicaid privatization who is primary caregiver for a daughter with intellectual disabilities, Jochum faulted Foxhoven for hiring the top Medicaid administrator from Kansas to run Iowa’s program in November. The DHS director promised members of the Senate Human Resources Committee in January, “I’m going to make it work. I believe we are down the managed-care course at this point, and that’s where we’re going to stay […] I’m going to do everything I can do to make sure it’s successful.”

Yet the system is “trapping sick and elderly patients in endless appeals,” a Des Moines Register investigation found recently. Many service providers are still not getting paid on time. According to Jochum, the insurance companies handling Medicaid cases owe Hillcrest Family Services in Dubuque $4.9 million, with some outstanding bills dating to April 2016, when state government implemented the new system. “This is just absolutely not working. It’s not working,” she repeated during our interview.

A few Republican lawmakers have acknowledged serious problems with Medicaid. The most outspoken is Senator Tom Greene, who told a Burlington audience in December, “When this was bought forward by (former) Gov. Branstad a year-and-a-half ago, I was cautiously optimistic that it would work,” said Greene. “It has not. I do not have one provider in southeast Iowa that has said this has been a positive measure.” Last month, he said of the “MCO mess,” “Clearly it’s not working in Iowa.”

House Speaker Linda Upmeyer told reporters in January that Medicaid “has not improved enough, fast enough, that anyone is comfortable with it.”

Upmeyer said she has heard “loud and clear” from House Republicans that they expect Medicaid to be fixed, adding, “and if it requires our attention, then it will.”

Neither House nor Senate Republicans leaders have shown any interest in legislation to address the problems, though.

In September, Foxhoven admitted that patients with severe disabilities “may not be the right mix” for managed care and hinted those people might be moved back into state-run Medicaid. But he didn’t follow through and now faces little pressure to do so. Last month a federal judge dismissed a lawsuit brought by six Iowans with disabilities who said the state failed to stop private insurers from illegally reducing the services they receive through Medicaid.

A Democratic bill that would have transferred Iowans needing long-term care back to state-run Medicaid died in the Senate Human Resources Committee this session. Jochum told me Foxhoven “has done nothing to help us” with that bill, or with legislation designed to force MCOs to reimburse for services within a set number of days. “Those MCOs gladly take money from taxpayers every month,” Jochum pointed out, but the DHS doesn’t force them to pay service providers on time. There is no sign Foxhoven has used his position to lobby Reynolds to improve the program. “When do you advocate for and represent the people the department was created to serve?” she wondered.

Besides asking Foxhoven to provide short-term and long-term plans for fixing Medicaid, Jochum said, Democratic lawmakers have expressed concerns about the ability of DHS to prevent tragedies like the deaths of two abused children with a vastly reduced staff of social workers. Moreover, the DHS director shocked some Democrats by testifying at an Iowa House public hearing in February that his department could absorb some $6 million in spending cuts during the remaining months of the current fiscal year.

Assuming all 29 Senate Republicans support Foxhoven, he would need five more votes from among the chamber’s 20 Democrats and independent Senator David Johnson, who has blasted the Medicaid privatization policy. Johnson told me via e-mail that reports the director’s nomination is in trouble “hold a degree of truth.”

Mr. Foxhoven has my vote for confirmation, and I have told him that. But not without sharply criticizing new Medicaid director Michael Randol.

Strike one, Mr. Randol comes to us from Kansas, the veritable wasteland tied to state government-destroying tax cuts.

Strike 2, he has told lawmakers he is “data-driven” with all the charm of Dracula. That attitude doesn’t bode well for Iowans with disabilities and other adults and children with chronic conditions — the most vulnerable and least among us.

Acting director Foxhoven assured me he has addressed the concern many of us have with Randol. The new Medicaid director and I got off to a bad start last month. The ball, as they say, is in his court.

Keeping one’s word is a key pillar in maintaining integrity as a lawmaker. Jerry Foxhoven has my vote. It would take a major department breakdown for me to change my support for confirmation.”

Senate Minority Leader Janet Petersen replied to my inquiry,

Our caucus has not taken a vote count or communicated anything to Governor’s office about the confirmation of Jerry Foxhoven or any other gubernatorial appointments. It would be premature for me to discuss his fate.

I also sought comment from the other Democrats on the Human Resources Committee: ranking member Liz Mathis, Joe Bolkcom, Amanda Ragan, and Herman Quirmbach. Quirmbach confirmed by e-mail that he opposed Foxhoven’s nomination in committee, adding,

As to a floor vote, it is my view that he has to make the affirmative case for his nomination. Given the total mess of the MCOs and privatized Medicaid, that may be a high barrier. I would want to hear from him a specific, concrete, detailed plan for getting clients the care they need on time and for getting providers paid fairly and on time, both with a lot less paperwork hassle than what they have experienced the last two years. The burden of proof is on him. Let’s see what he has to say.

I also want to hear what he has to say about staffing and oversight for child welfare. I want specifics for what he is going to do to prevent another Natalie Finn/Sabrina Ray tragedy from happening.

I’m still willing to listen, but I will need solid, convincing answers if he hopes to win my vote.

Foxhoven is reaching out to individual senators for support, Jochum said. Senators confirmed the previous Iowa DHS Director Chuck Palmer unanimously in 2011 but with just five votes to spare when he was renominated four years later. Branstad had disclosed his Medicaid privatization plan during the 2015 legislative session–private insurance companies had been informed much earlier–but the policy hadn’t gone into effect. Other controversies related to the closure of the Iowa Juvenile Home and state-run mental health facilities nearly derailed Palmer’s nomination.

Seven of the eleven Democrats who voted against Palmer three years ago still serve in the legislature: Jochum, Petersen, Quirmbach, Tod Bowman, Rita Hart, Rob Hogg, and Rich Taylor.

Eleven of the fifteen Democrats who voted to confirm Palmer in 2015 still serve: Mathis, Ragan, Bolkcom, Chaz Allen, Tony Bisignano, Jeff Danielson, Bill Dotzler, Bob Dvorsky, Wally Horn, Kevin Kinney, and Matt McCoy.

The best case against confirming Foxhoven is that someone must be held accountable for this policy’s harmful and in some cases life-ruining consequences for Iowans who can’t get the care they need. Why give Foxhoven a vote of confidence when he hasn’t fixed his department’s biggest problem?

The best argument for Democrats to confirm the DHS director that if they don’t, Reynolds will probably appoint someone worse. Foxhoven came into the job with a lot of goodwill among Iowa progressives because of his many years of advocacy work related to child welfare and racial disparities. Jochum acknowledged during our interview, “He has done a lot of good work on the outside for juveniles.” At the same time, “This is not a personality contest.” Many Democrats want to see substantive changes from this administration on Medicaid.

UPDATE: Republican leaders brought Foxhoven’s nomination to the Senate floor on March 7, but Democrats asked to delay a confirmation vote. The Iowa Senate Democrats released this statement from Petersen:

“We made a reasonable request today to delay the confirmation vote on Jerry Foxhoven until we can fully assess his leadership at the Iowa Department of Human Services.

“First, there’s no need to rush this important decision. The deadline to deal with confirmations isn’t until April 15.

“Second, there are too many unresolved problems with the privatization of Medicaid services by the Reynolds Administration. This is particularly concerning because Governor Reynolds promised in her Condition of the State address this year that Jerry Foxhoven and other new members of her team would:

· Resolve issues for caregivers ‘in a timely manner and ensure on-time payments.’

· Reach patients in ‘new and innovative ways to individualize their care.’

· ‘Make it right.’

“There’s no evidence today that she has kept those promises or has a plan for addressing the concerns of Medicaid recipients, health care providers and Iowa taxpayers.

“In addition, Senate Democrats have concerns related to:

· Plans to turn the Iowa State Training School for Boys in Eldora into a correctional facility.

· Foxhoven failing to raise red flags about the impact of mid-year budget cuts on critical services provided by the Department of Human Services.

· Doubts about the state’s ability to ensure the health and safety of vulnerable Iowa children.”