Julie Hamos spent almost 12 years in the Illinois General Assembly representing a diverse House district in Cook County, championing laws to fight domestic violence and dealing with difficult urban issues involving mass transit, housing, the environment and human services.

But even that experience and years of toiling on behalf of low-income people and unionized workers didn’t fully prepare this daughter of Holocaust survivors for the political and economic headwind she would face after Gov. Pat Quinn appointed her director of the Illinois Department of Healthcare and Family Services in April 2010. She began the job two months after losing the Democratic primary for U.S. Sen. Mark Kirk’s former U.S. House seat in a race that eventually would be won by Republican Robert Dold.

Hamos, 62, a lawyer who lives in Evanston and is married to former state Appellate Court Judge Alan Greiman, heads one of the state’s largest agencies. HFS operates with an $18.5 billion annual budget, 2,241 full-time employees and a Medicaid program that covers 2.8 million Illinoisans. She is paid $142,339 annually.

Her first year and a half on the job has been anything but calm.

The state’s ongoing budget crisis is causing increases in payment delays for doctors, hospitals and others providing services to Medicaid patients.

Allegations by losing bidders that the state’s contracting process for state employee group health insurance was unfair have landed Hamos and HFS in court and pitted her against some former colleagues on the legislature’s Commission on Government Forecasting and Accountability.

Pressure from lawyers and others representing senior citizens and their families has put Hamos at loggerheads with the legislature’s Joint Committee on Administrative Rules. She said the panel of lawmakers is jeopardizing billions in federal Medicaid matching dollars by blocking a 2005 federal law that restricts the ways seniors needing nursing-home care can shelter assets.

All of that is happening while Hamos works to implement a state Medicaid reform law designed to get more control over the spiraling costs of the program and improve the care that Medicaid patients receive. The law dovetails with a statewide health-insurance “exchange” that is scheduled to launch in 2014 as part of the federal Affordable Care Act.

But Hamos, who as an 7-year-old girl fled Hungary with her family during the Hungarian Revolution in 1956, hasn’t lost her sense of humor and the ability she displayed as a legislator to multitask and avoid becoming cynical. She mixed laughter with concern during a wide-ranging interview with Dean?Olsen for Illinois Issues in her Springfield office. The following is an edited version of that discussion.

Q. Why did you decide to become a member of the governor’s Cabinet, especially at this time, when the budget situation is so challenging? 
I was offered this job three weeks after the president signed the Affordable Care Act. And I knew it was coming down to the state level and that Illinois had to get it right. This was the president’s state. It was going to be an incredibly important challenge to implement national health care reform. And that was a very big, exciting challenge to me, and that’s really why. And I respect the governor. This is a good governor, with a good heart, a good set of values. I’ve known him for a long time. 

Q. What has the transition been like for you from legislator to member of the executive branch?
It makes me realize how much easier my previous job was, although running for office has its set of challenges. Of course, you have to be very active and involved in your community and spend a lot of time at it. And you have to spend a lot of time raising money — that’s not fun. But in terms of policymaking, it was something I knew, I enjoyed. I did take on big, challenging issues. I had a good degree of success. Now, I have to really deliver health care for 2.8 million people on Medicaid and 420,000 people in the group health insurance plan. We have to implement laws in a very different way, and it’s a big responsibility to do this well and to create an efficient, effective system. So it’s a much different level of responsibility.

Q. What sort of surprises have you encountered in this job?
The biggest surprise, and still the biggest challenge, is how slow the bureaucracy moves. It is stunning. The procurement process is very lengthy, and it takes an amazing amount of effort to contract with good vendors that we need to help do our work. And then the second part of it is that for the Medicaid program, more than any other program probably, it crosses so many other agencies. As a legislator, I complained about it, I saw it, but I didn’t realize how hard it is to break down the silos of government, and we have to do it every single day because our Medicaid clients have issues and needs that affect the Department of Human Services, Department of Public Health, Department on Aging. We just cross a lot of different agencies.

Q. You can’t tell those agencies what to do?
Correct.

Q. They have their own bureaucracies, don’t they?
Right. So that’s a big challenge, I’d say.

Q. You work for a governor who says he’s progressive. There are certain things in state government that aren’t possible to change? 
It’s slow.

Q. Does it need to be that slow, or is it just the nature of government?
I don’t think I know the answer to that. But we are a 96 percent unionized workforce. I support unions, but I also think we need managers. I’m OK with a balance. We don’t have enough managers, and we haven’t treated our managers as well as we have our unionized workforce. That’s a problem, so it’s difficult to attract people into state government right now because they are subject to furlough days — it’s really the merit comp employees who have gotten the short end of the stick here. And that’s why so many people have gotten into the union and have wanted into the union. The union rolls have increased substantially since the Blagojevich period because we haven’t treated the managers very well.

Q. You have talked about how you’re changing Medicaid from a program that processes claims to a health-care delivery system. What’s the status of that transition?
This is a very important culture change inside our agency right now. We are not just focused on paying bills and bringing in federal Medicaid match. We are much more focused now on how we can get our providers to deliver health care so that there are better health outcomes, so people are healthier. We believe that we can save costs in Medicaid by keeping people healthier. And that means doing more preventative health care and getting people more effective health care at better costs, and that’s really our strategy. And I think it will really pay off, and it’s to me the underlying theme of national health-care reform … and what I now believe, more than ever, is going to be demanded of us moving forward. “Care coordination” is what we’re really talking about. That will, in fact, produce better results, and it will be a more effective health-care delivery system. But it’s a big change.

Q. What’s the status of the health-insurance exchange that Illinois plans to create through the Affordable Care Act?
We are actively planning for the health-benefits exchange — our agency and the Department of Insurance. What’s exciting about this for us is there are two components for the exchange: a consumer-friendly website where individuals and small businesses will, in a very easy way, look at offerings of health-insurance products, compare them, figure out what they want to buy and to sign up for it. And in some cases, people will sign up for it, and they will qualify for Medicaid because they will be under a certain income, and in other ways, they will qualify for tax subsidies to help them pay for health insurance. The part where they will qualify for Medicaid is a very important component of our work because we need to streamline and make more efficient our whole system of enrolling Medicaid clients.

Q. Would you like to get the exchange up and running early — before 2014? (The federal law allows early implementation, but the big federal subsidies for covering the estimated 600,000 to 700,000 people who will be added to Illinois’ Medicaid program won’t be available until 2014.)
I’ve been resisting that. Under our state Medicaid reform law, right now we’re under a two-year moratorium not to expand eligibility for Medicaid. The legislature wanted us to put it in that bill, and we agreed with it because our Medicaid budget is already very constricted. We will be bringing into the Medicaid system a whole new group of people, and many of them are people who have not had access to health care. They’re going to be sick. They’re going to be needy. They’re going to be substance abusers. They’re going to be ex-offenders. They’re going to really need good health care. But we have to fix the care-coordination system first, because just to bring in a whole bunch of people and have them shop around would cost a lot of money, and it wouldn’t be the most effective health care.

Q. Your agency has launched a pilot project for care coordination involving 40,000 disabled adult Medicaid recipients in the Chicago area. How is that project going?
It really got launched a few months ago. The biggest problem we’ve had, and I’m really concerned about it, is that [some] clinics, doctors and hospitals don’t want to sign up for the program. Even when they’ve been serving their disabled patients for a long time, they refuse to sign up for this. We don’t understand what’s going on exactly. This is new for Illinois. It’s not the old Medicaid system. We’re trying to convince all these different groups out there that this is the future. If there’s been any problem at all in getting that organized, it’s really that.

Q. Does that situation not bode well for the future of care coordination in Illinois?
It’s something we have to work on. I think, in part, Illinois has been pretty resistant to managed-care companies, not only in Medicaid but in the private market. Doctors and hospitals don’t like anybody looking over their shoulder. We want somebody looking over their shoulder. It’s a difference of philosophy. We think that better coordination will mean, in fact, somebody asking questions about the care being received.

Q. What do you think is your biggest challenge right now as the director?
Every single thing I’m doing is a challenge as the director. I can show you my calendar — all day long, every day. I have had a long history and a very exciting career of making change and being a policymaker. But being a change agent is very difficult, and ultimately, people are fearful of change. It’s very difficult to be a positive force for change but to really push the envelope on getting people to change the way they do things.

Q. Are there any misperceptions about Healthcare and Family Services?
I think there are misperceptions about the Medicaid clients that we serve. I’m troubled when I read emails I receive that are very angry at low-income people who depend on Medicaid and who depend sometimes on some other welfare benefits. We have 2.8 million recipients. I’m sure there’s fraud. I’m sure there’s abuse. There’s no question about that. I would like very much to attack it and root it out. That’s a big goal of mine because the integrity of the program is very important to me.

Q. Have you lost any friends in the legislature, or have relationships been strained, because of what you’ve had to do as director?
I think I’ve had a little bit of a honeymoon with the legislature, but honeymoons do end. I’ve said to them, “This is going to be hard, and we’re going to be at different sides of a table.” It’s going to be difficult. We are taking on so many big challenges. Some of them could fail. We can’t assure perfection in all things.1

Dean Olsen is the medical/health reporter for the State Journal-Registerin Springfield.

Illinois Issues, October 2011