Escalating health challenges for inner city Milwaukee

Two recent reports have raised concerns about healthcare access for low-income Milwaukeeans. First, The Business Journal Serving Greater Milwaukee reported on Aurora Health Care’s relocation of orthopedic and heart surgeons from its Sinai Medical Center, located just west of downtown, to a new hospital in Grafton. The transfers have caused some to fear further service reductions at Sinai, particularly in light of the decades-long trend of hospital closures in the City of Milwaukee. Days after the Business Journal article, the Center for Urban Population Health (CUPH) released a report revealing entrenched health disparities among Milwaukee residents based on socioeconomic status. With state budget cuts to Medicaid as an additional hurdle on the horizon, are the healthcare challenges facing low-income Milwaukeean’s about to get even worse?

Since 1977, nine hospitals have closed in Milwaukee, including the 1995 closing of the county-owned John Doyne Hospital, which had long served as a safety net for the uninsured. Initially, these losses were tied to the city’s population decline, but the most recent closings – Northwest General in 2000 and St. Michael’s in 2006 – occurred despite a stabilization of the city’s population during the past decade. Another major factor that has been linked to hospital closings in the city is a dramatic increase in poverty, which has resulted in higher rates of publicly insured and uninsured residents.

Despite the fact that Sinai has operated at a loss nearly every year over the past decade, Aurora Health Care maintains it is committed to downtown Milwaukee. But with the state’s proposed $500 million in Medicaid cuts over the next two years, private hospitals may be faced with further cuts in Medicaid reimbursement and/or an increase of uninsured patients. The details of the state’s Medicaid budget have not been announced yet, but the BadgerCare Plus Core plan for childless adults had already instituted a waiting list long before budget debates began.

Milwaukee’s healthcare safety net for the uninsured has gone through several changes over the past 20 years. The county’s John Doyne Hospital served the uninsured free of charge until it was closed by county officials in 1995. To partially replace Doyne Hospital, Milwaukee County created the General Assistance Medical Program (GAMP), which provided health coverage for low-income, childless adults – the portion of Milwaukee County’s low-income population that didn’t qualify for Medicaid at the time. When the State of Wisconsin expanded BadgerCare in 2009 to cover childless adults, the GAMP program was eliminated. Consequently, if BadgerCare eligibility is now restricted in response to the state’s Medicaid funding gap, there will be no public safety net program to provide backup.

Milwaukee’s four federally qualified health centers (FQHCs), which provide primary care services to patients regardless of their ability to pay, fill an important role in serving the city’s uninsured. All four centers are expanding their operations and together may be positioned to take on additional patients in the near future. In addition, the downtown AIDS Resource Center of Wisconsin (ARCW) clinic is working to become a fifth primary care FQHC, which would allow it to serve many more patients. These are encouraging signs, but capacity constraints remain a concern at the FQHCs and continue to be a focus of the health system leaders who comprise the Milwaukee Health Care Partnership.

As the local impacts of the state’s Medicaid budget are revealed, there may be even greater strains on the regional healthcare system. A key question is whether Milwaukee policymakers and healthcare leaders will be able to respond as quickly and effectively as the demand for services may warrant.

Region's property taxes kept under control in 2011

The Public Policy Forum's annual analysis of property values and property taxes in the seven-county southeast Wisconsin region - released this morning - finds that the amount of gross property taxes levied by local governments, school districts, technical colleges, special districts and other entities across the region increased by just 1.5% in 2011. That's the lowest year-to-year increase since at least 2000, and well below the 10-year average of 4.3%.

The relatively small increase in total levies, however, was accompanied by a 6% increase in the aggregated gross tax rate for municipalities and school districts in the region, from $20.36 per $1,000 of property value in 2010 to $21.58 in 2011.

For those who might be confused about how levies could increase only slightly when rates increased substantially, the key is property values. A municipality’s tax levy is determined by both the total property value in the municipality and the tax rate that is applied to that value.

Because property values decreased 4.2% between 2009 and 2010, local taxing entities needed to collectively increase the tax rate by $1.22 to realize the 1.5% increase in the amount of property tax levied. Conversely, five years ago, when property values in southeast Wisconsin increased nearly 11%, the region’s local governments and school districts were able to collectively increase tax levies by 5%, while at the same time decreasing the aggregate tax rate by $1.10 per $1,000 of assessed value.

The relatively small property tax increase is good news for taxpayers, but the report points out that it also may raise questions regarding the capacity of the property tax to support desired levels of local government services. Indeed, such annual increases are likely to become the norm – even after the economy rebounds – in light of strict new property tax limits adopted by state government.

Whether the breadth and quality of local government services will suffer with lower property tax capacity remains to be seen. This is an issue that bears watching, however, and one that may produce a need for renewed debate and discussion of revenue diversification for local governments and school districts in Wisconsin, strategies to share or consolidate local government and school district services, or acceptance of lower service levels.

The full report can be accessed here, and our media release here.

Apps for Milwaukee

The open government data movement is a global effort to increase government transparency, civic participation and innovation through public access to municipal data. In the age of the ubiquitous software application (app) for use via personal computer or mobile device, governments around the world are profiting from the creativity of tech-savvy citizens by making data available for the development of useful apps. Since 2008, several U.S. cities, including Washington D.C., San Francisco, and, most notably, Chicago, have started to share government data and even sponsor competitions to encourage the creation of innovative local apps.

Could open government data improve quality of life in Milwaukee? Perhaps Chicago’s experience will help answer that question. Apps for Metro Chicago, which launched on June 24th, is currently accepting submissions for the first of three rounds of competition. The first round seeks apps aimed at improving transportation in the Chicago metro area, with subsequent rounds focusing more broadly on solving community problems and improving services. With $50,000 in prizes, the public will help to choose the winners by voting for the apps they believe are most useful.

Apps for Metro Chicago is the first competition of its kind to involve four levels of government: the City of Chicago, Cook County, the Chicago Metropolitan Agency for Planning, and the State of Illinois. Together, these governments have made more than 175 data sets available to the public in an open format. These data sets range from municipal service requests to hospital information to neighborhood demographics.

Chicago’s competition is also unique in its emphasis on rewarding civic value. The judges will grant bonuses for participants who partner with a business or nonprofit to solve a real, local problem. As the competition’s website states, “the key to winning this contest is to demonstrate that you have created something useful for our community.”

In addition to rewarding community partnerships in the judging phase of the competition, Apps for Metro Chicago is actively helping to connect community organizations looking to solve specific problems with citizens with the skills to create apps. Metro Chicago Information Center (MCIC), the research and consulting group coordinating the competition, is working to make these kinds of connections. One interesting partnership is a collaboration between a local industrial retention initiative and an app developer to write a truck routing app that takes into account weight limits, clearances, road blockages, and other factors to improve the efficiency of distribution.

The accessibility of government data in Milwaukee certainly would impact the replication of a similar competition here. The City of Milwaukee has COMPASS and Map Milwaukee, useful web-based tools that provide municipal data on local demographics, property, crime, traffic accidents and more. These applications allow Milwaukeeans to query information and create maps, but the data is not in an open format and thus cannot be easily reused and shared. The Nonprofit Center of Milwaukee also makes a limited number of data sets available for public use, including information on neighborhood demographics, crime, and geography. Their Data Center also provides technical assistance to the public to help make the data easier to understand and utilize.

One Milwaukee-specific app that has already been developed is the Milwaukee County Transit System (MCTS) bus tracker, which estimates bus arrival times. It can be downloaded for iPhone or Android mobile phones. While certainly a useful tool, the bus tracker tool bases its estimates on set route schedules and could be improved by utilizing the GPS technology already used by MCTS buses to report arrival estimates in real time. Similar real time apps have been created in many U.S. cities, including Chicago.

If the city, county, and other government bodies opened their data sets to public use, the possibilities could be endless. Judging by developments in other cities, it is possible to imagine apps that allow us to find out what’s happening in Milwaukee neighborhoods on a given day along with information on where we can park our bicycle or car nearby, report potholes on our streets and receive notification of repairs, or keep us updated on how our representatives at all levels of government vote on important issues.

With resources like COMPASS, Map Milwaukee, and the Nonprofit Center of Milwaukee’s Data Center, Milwaukee is in a good position to take the next step by making more municipal data available in an open format. Creatively using such data could be a simple and cost effective way to make government more useful to today’s tech-savvy citizenry.

Milwaukee County's alarming budget prognosis

For those who hoped the changes to collective bargaining or the arrival of a new county executive might finally solve Milwaukee County's longstanding fiscal problems, we are sorry to disappoint. The Public Policy Forum's 2012 Milwaukee County Budget Preview report - released this morning - shows the county's budget prognosis actually has worsened since last year, leaving it with "few remaining strategies outside of deep service cuts and/or sharp revenue increases."

This is our first report analyzing Milwaukee County's finances since the adoption of the state budget repair bill and 2011-13 state budget. Our analysis confirms that the county realizes substantial savings from the budget repair bill's labor provisions, likely exceeding $24 million in 2012. Unfortunately, about $17 million of those savings already were built into the county’s base budget in 2010 and 2011. Thus, while the net savings of $7 million for 2012 are significant, they do not come close to offsetting the nearly $29 million in state aid reductions contained in the latest state budget.

Additional key findings and observations from the report:

• Our modeling of several approaches for bridging an estimated $38 million 2012 gap shows potentially stark impacts for county employees, services, programs, and/or taxpayers. Those include deep cuts in mass transit and community-based mental health and disabilities services; severe reductions in parks and cultural amenities and exhibits; and additional reductions in health care benefits that could greatly exceed those imposed on other public sector workers in Wisconsin.


• Because the county may have a one-time opportunity to boost its property tax levy by nearly $10 million in 2012, there is a limited timeframe to include significantly enhanced local revenues as part of the county's deficit-reduction strategy. The only other local broad-based tax or fee available to the county is the vehicle registration fee, which could be used to generate additional revenue for transit or other transportation needs, but which has generated considerable political opposition.


• A five-year fiscal outlook prepared by the county before adoption of the 2011-13 state budget showed a noticeable improvement over the five-year forecast from a year ago. Once the impacts of state aid reductions from the state budget were plugged into the model, however, the county’s five-year outlook became even worse than that forecasted in 2010, despite the budget repair bill’s provisions giving the county unilateral control over many labor and benefit costs.

The report concludes by noting that because the county now has greater certainty and flexibility with regard to its employee compensation framework, its ability to engage in strategic planning has been greatly enhanced. While that won't make the tough decisions any easier, it does allow county officials to reliably size up their fiscal situation and, ideally, finally reach consensus on a realistic scope of county services going forward.

The full report can be accessed here, and our media release here.