Enhanced Role for Nursing in Milwaukee County's Redesigned Mental Health System

Few would dispute the idea that effective mental health care relies on the quality and accessibility of health care professionals, especially nurses. As stakeholders in Milwaukee County work to redesign the county’s mental health system, one of the crucial issues they face is how to build an effective and efficient mental health nursing workforce in light of anticipated changes under the new system.

The Nursing’s Voice project is a collaborative effort of local and national foundations, higher education institutions, and other interested parties to enhance the supply of mental health nurses in Milwaukee.  As part of the project, the Forum surveyed 120 mental health nurses and 34 employers to illuminate the state of the county’s current mental health workforce and to gather insights to inform the redesign planning process and the work of Nursing's Voice.  

Survey responses identified three broad categories of need that an effective redesign effort must address – the need for training and professional development of nurses, specifically in mental health care; the need for a larger mental health nursing workforce today and in the future; and the need for nurses and employers to clarify their respective expectations about what constitutes effective mental health nursing skills and practices. In the research brief that summarizes the survey findings, the Forum describes key policy implications:

• Because of a perceived need for nurses with an interest in mental health both now and in the future, incentives for increasing the mental health workforce might be necessary. The redesign process should also anticipate the need for more nurses. 
• Although employers are satisfied with the mental health nurse applicant pool, very few nurses are nationally certified or advanced practice nurses. This suggests that while schools of nursing provide a basic foundation of mental health training, planners should explore possible reasons for the apparent lack of deeper knowledge and discern how this deficit will affect future service provision.
• Employers envision a larger role for mental health nurses in outpatient/community settings. However, today most nurses work in inpatient settings. Planners should explicitly consider the optimal roles of nurses in community health settings.
• Turnover among mental health nurses is relatively low (less than 10%) with the greatest source of job satisfaction deriving from patient care. Sources of job dissatisfaction are related to pay and advancement. If nurses’ responsibilities become more administrative or policy-oriented under a redesigned system, the reduction in patient contact may cause nurse job satisfaction to suffer (and attrition to rise), particularly if wages do not change.
• Employers and nurses lack consensus about which skills are most important for patients’ recovery. This suggests either a lack of clear communication or differing expectations as to the job objectives. Employers and nurses should work toward greater clarity about these differences if the role of nurses is to change under a redesigned system.
• Employers and nurses find more common ground regarding their views of the specific skills that need strengthening. Planners should therefore focus future professional development resources in these areas.
• Both nurses and employers placed specific importance on the ability of nurses to understand the treatment needs of patients diagnosed with dual/co-occurring disorders in which mental illness coincides with substance abuse. As the county shifts its focus to dual/co-occurring disorder treatment, the need for improved training for nurses will be imperative. 

These findings could serve as guideposts to planners, employers, and nurses themselves as they navigate the uncharted territory of a redesigned mental health care system in Milwaukee County. In addition, Nursing’s Voice will play an active role over the next two years to bring the perspective of mental health nurses to both the redesign and implementation of the new system. To do this, the collaborative partnership will undertake three key activities: 1) conduct research and data collection, such as this survey, to document the current and future need for mental health nurses in the new system; 2) develop strategies to encourage nursing students to pursue a career in mental health service and to provide them with the essential skills to be successful; and 3) provide a platform for the voice of nurses so that the new mental health delivery system can make optimal use of their skills and ideas.

County's finances on the upswing, but big hurdles remain

The Public Policy Forum released its annual review of the Milwaukee County Executive's recommended budget today, and the tone is decidedly more upbeat than in previous years. Because of a smaller (but still substantial) budget gap heading into the year, and thanks to an unexpected $13 million 2011 surplus, this year's county budget is the least difficult in years.  As we point out in our report, multi-year efforts to manage the county's health care benefits and limit long-term borrowing are paying off, though pressing long-term problems remain.

A focus of this year's budget brief is whether the county executive and his budget team seized the opportunity provided by the convergence of these positive circumstances to make continued progress on long-term structural problems, or simply viewed the 2013 budget as a one-year blueprint. We find that, on the whole, the budget responsibly addresses both short-term and long-term issues, though it also leaves the county short on reserves and long on infrastructure repair needs.

Commendable efforts to address immediate fiscal needs include a clean-up of outdated revenue projections in the Behavioral Health Division and Parks budgets; the use of some of the 2011 surplus to cash finance infrastructure repairs; and investments in long-neglected areas of administrative infrastructure, including human resources and information technology.  We also cite the budget's clear priorities when it comes to budget-cutting - which contrasts positively from the across-the-board approach used in many previous years - and the absence of rosy revenue projections and short-term fixes.

The report also cites concerns, however, about the methodologies used to justify big changes to the sheriff's budget, and raises questions about the long-term feasibility of continued cuts in health care benefits and a decision to spend the balance in the county's Debt Service Reserve.

We conclude that, overall, the recommended budget "should be seen as one that proposes several foundational steps that allow the county to continue its path toward financial stability.  Nevertheless, the county's stagnant revenue streams, continued fringe benefits burden, immense infrastructure needs and lack of reserves - combined with the still tenuous legal standing of its recent pension and health care changes - suggest that years of heavy lifting yet will be required before its journey is complete."

The 2013 Milwaukee County Executive Budget Brief can be accessed here.  Our review of the mayor's proposed 2013 budget for the City of Milwaukee will be released early next week.

Revisiting the role of counties

The title of an article by Alan Greenblatt in this month's Governing magazine asks a question that has received considerable attention in Milwaukee County during the past few years: Are counties "an outdated concept or the future"?  

Local businessman Sheldon Lubar aggressively raised that question in 2008, when he suggested in a speech to the downtown Rotary Club that Milwaukee County government had grown so dysfunctional, it wouldn't work "if Jesus was the county executive and Moses chaired the board of supervisors."  He suggested that the government gradually be dissolved, with its functions spread out to state government, municipalities and regional authorities.

In January 2010, the Public Policy Forum weighed in on the subject with a 160-page analysis commissioned by the Greater Milwaukee Committee.  Our report, "Should it Stay or Should it Go," detailed the logistical, legal and political hurdles that would complicate an effort to dismantle the county, and suggested that alternative restructuring approaches - such as consolidating certain municipal functions at a county or regional level - also be considered. 

Interestingly, the Governing article reveals that virtually identical debates are occurring in other parts of the country.  It cites cases of elected and civic officials who have grown so frustrated with the financial problems and/or dysfunction of their county governments that they are suggesting those governments be dissolved, and other cases where leaders are pushing for the opposite approach of growing their county governments by having them absorb municipal functions.

Another important take-away from the Governing  piece, however, is that while we can and should think about radical restructuring as a response to county government financial woes, we should not allow such contemplation to preclude action on strategies that are less comprehensive, but that may be effective nonetheless.

As Greenblatt puts it, "the growing disconnect between the demand for services and the general county-level ability to pay for them has led to a round of structural changes in the ways that counties do their business. For one thing, counties are outsourcing and privatizing like never before. And they are collaborating more with other governments than they ever have, both with the municipalities and special districts within their borders and with other counties in their regions."

Greenblatt cites examples of county governments across the country that are teaming up with adjacent counties to provide health and human services, or offering their municipalities the opportunity to contract with them for information technology and public works.  He also suggests such initiatives would not have occurred had counties not had a "financial gun to their head."

Whether or not one agrees that lethal fiscal threats are a good thing, applying that principle to our circumstances in Milwaukee County may make sense.  There has been ample discussion about the need to pursue service sharing and functional consolidation at both the municipal and county levels, and a few notable recent examples of success in our region (e.g. consolidated dispatch centers in Racine and Waukesha counties) and in Milwaukee County (e.g. partnerships between Milwaukee County and adjacent counties for delinquency services and Family Care).  Still, movement toward meaningful service sharing between Milwaukee County and its municipalities has been somewhat slow.

While Milwaukee County's fiscal fortunes appear to have improved somewhat in recent weeks, deep structural problems remain.  Greater collaboration with municipal governments in functions ranging from property tax collection to public works remains a promising yet largely untapped area of potential relief.

Measuring Milwaukee County Juvenile Justice Recidivism

To what should Milwaukee County attribute its declining adult and juvenile detention population? This question took shape in a research brief published a year ago by the Public Policy Forum, entitled “Milwaukee County Detainee Populations at Historic Lows: Why is it happening and what does it mean?” In that report, the Forum urged county law enforcement officials and policymakers to consider whether justice system policies that may have contributed to the decline were effective and should be sustained.

Milwaukee County’s Delinquency and Court Services Division (DCSD) asked the Forum to help in making that assessment for the array of services it offers to youth in the juvenile justice system. Success in curbing repeat delinquent behavior can have impacts into adulthood, making the juvenile justice system one critical piece in efforts to control crime and its related costs. 

The most common way to assess the success of juvenile delinquency programming is to measure the extent to which participants commit additional crimes, otherwise known as recidivism.  However, the best approach to defining a recidivistic event is not always clear cut, with many variations seen nationally.

The Forum’s newest research brief reviews the manner in which DCSD defines recidivism and its progress in reducing it.  The following points summarize our findings:

• Using DCSD’s recidivism methodology, we find no significant changes in recidivism over five cohorts of youth aging out of the juvenile justice system between 2006 and 2010.  However, categorizing youth based on the year in which they age out of the system (i.e. turn 17-years-old) has its limitations, as this approach blurs impacts of year-to-year policy and programmatic changes.
• Under our alternative methodology for measuring recidivism, we categorize youth by the year in which they are referred for their first delinquent offense and allow for a uniform follow-up period.  Using this method, we find lower rates of recidivism for youth first referred in 2007 and 2008 than in the prior three years. Although two years of improved outcomes do not guarantee a new trend, this positive improvement begs further research into whether changes made in policy or programs during that time could be the cause.
• Under either measure of recidivism, we find a small group of chronic offenders accounts for a substantial percentage of repeat offenses, a trend often seen nationally.  Consequently, increased attention to programs and strategies aimed at chronic offenders may be warranted.
• It may be appropriate for DCSD along with other justice system officials to carefully contemplate which recidivism definition or set of definitions would best achieve performance assessment goals in the future.

Recidivism likely will continue to be the most prominent outcome measure used by policymakers in Milwaukee County to understand the performance of juvenile justice programs. Continued progress in developing and standardizing this evaluative tool will be critical as a means of helping the county's juvenile justice system articulate system performance and improve the spectrum of services it provides to county youth.

Our research brief, commissioned by DCSD, can be accessed here.

Should we be concerned about the decline in family child care providers?

During the debates over Wisconsin's new child care quality improvement initiative, the YoungStar quality rating system, it became clear that an anticipated trade-off for quality improvement was likely to be a reduction in the number of child care providers.  The providers predicted to most likely be negatively impacted were family child care providers (who care for small numbers of children in their own home), as the new quality standards would differ dramatically from the current certification and licensing requirements for these providers. In addition, the Forum's own survey work found family child care providers to be less likely to have the financial and organizational resources needed to make significant investments in quality.  Finally, many observers felt there could be an over-abundance of family child care providers, particularly in Milwaukee County, and that increased parental demand for higher quality care might expose that reality.

In fact, according to a recent analysis by the Wisconsin Council on Children and Families (WCCF), there has been a significant decline in the number of family child care providers, as compared to years prior to YoungStar.  Statewide, there has been an 28% decrease in the number of family providers over the past seven years, including a 63% decrease in the number of certified providers, who had the least rigorous regulatory requirements prior to YoungStar.  WCCF finds the drop in family child care providers in Milwaukee County to be even more dramatic, with a 33% decline in just the past four years.

Should these results be troubling?  It's hard to say.  While there is a need to monitor whether this reduced supply in the family child care market negatively impacts child care access, to date there is no indication that parents have less access to quality care despite the reduced number of slots.  The changes may simply mean the supply has adjusted to match demand.

Conversely, at least a few child care providers feel the new regulations, coupled with the state Department of Children and Families' focus on fraud reduction, are having an unconstitutional disparate impact on African-American child care providers in Milwaukee and several have filed a federal law suit.  Although the claim does not provide statistics, it does seem possible that most of the suspended licenses and certifications were held by African-American providers.  As of March 2012, of the 281 providers listed on the website of the Department of Children and Families as suspended, the vast majority (90%) are located in Milwaukee. The state does not report the race of these providers, but the Forum's 2010 survey of child care providers found that while 10% of Wisconsin's providers are African-American, the rate increases to 48% in Milwaukee County. Thus, to the extent Milwaukee providers make up most of the suspended providers, it is likely that African-American providers are over-represented among them.  Whether this is a disparate impact and, if so, whether it is intentional will likely be difficult to prove.  However, even if no intent is found, if the perception that the state is targeting Milwaukee's African-American providers is widespread in the city, it may prove to be a significant hindrance to the state's efforts to reach out to Milwaukee parents about the importance of choosing a high-quality provider.

Another concern may arise if the family child care providers who have left the market stay unemployed or leave the labor force altogether.  The Forum found in our 2010 report, "Moving the Goal Posts: The shift from child care supply to child care quality," that the state's restructuring of the subsidy program was likely to have unintended consequences for child care providers.  We cautioned that "if this system reform is to be effective, then it is important to understand that the child care system we have today is the result of policy goals originally designed to impact the supply of care..."  Reforming welfare and creating a new child care subsidy program enabled low-income parents to join the workforce, including thousands who found new jobs as family child care providers.  The subsidy program was designed to emphasize child care supply over child care quality in order to effectuate the goals of welfare reform. It is important to recognize that these supply-oriented actions created jobs in the child care market; dramatic quality-oriented changes in the market will now affect those same jobs.  


Finally, given the fact that family child care is less expensive than center-based care, any decrease in the supply may negatively affect families who cannot afford to utilize a child care center.  YoungStar is designed to make higher quality care more affordable to low-income families by increasing the subsidy rate for higher quality care.  Whether the increase is enough to neutralize the impacts of the decreased supply in the low end of the market over the long term is yet to be seen.  For now, families appear to be able to remain the in the regulated market.  However, there remains a potential for growth in cheap, unregulated care, which should be monitored.  

How does a new mental health facility fit into the county's infrastructure picture?

The decision last week by Milwaukee County's Health and Human Needs Committee to "put the brakes" on planning for a new inpatient mental health facility - as reported in the Milwaukee Journal Sentinel - was welcomed by many mental health advocates, who have been urging the county to prioritize community-based care and substantially shrink its inpatient capacity. That sentiment is largely consistent with the recommendations of a national consultant - the Human Services Research Institute - contained in a 2010 report co-authored by the Public Policy Forum.

But also embedded in the committee's decision - as reflected by comments from the county executive - is the encouraging recognition that any possible new mental health complex must be considered within the context of the county's overall infrastructure needs.

For the past several years, as supervisors and administrators have argued over where and how large to build a new mental health complex, they have done so without the perspective of an overall facilities management and capital financing plan. Such a plan is needed not only to provide a clearer picture of the breadth and cost of the county's total infrastructure challenges, but also to assess how a potential significant investment in a new mental health complex will jive with the county's limited borrowing capacity.

The need for such a plan also was hammered home last week by a new report from the county's parks director, which recommended spending $15 million in each of the next five years to address a significant infrastructure backlog.

To put that request into context, the county currently has a policy that caps annual borrowing for capital needs at a little over $30 million. That means if policymakers heed the recommendation and want it to be part of the county's annual general obligation bonding, then almost half the annual allotment would be used simply for repairs and maintenance in the parks. That, in turn, would leave little room for capital needs related to the Zoo, Courthouse Complex, corrections facilities, information technology, transit, economic development, and county trunk highways.

The good news is that per a recommendation of its Long-Range Strategic Planning Committee, the county has hired a consultant to perform a comprehensive analysis of its existing infrastructure and help develop a master infrastructure plan. It is within the context of that planning process and the ongoing deliberations about the nature of the county's mental health care delivery system that the discussion about a new mental health complex would best proceed.

The Forum's top five research findings of 2011

With the end of the year upon us, it’s time once again for the Forum to unveil its top five research findings of 2011. We started this annual tradition last year with a list that included findings on Milwaukee's skilled workforce, Milwaukee Area Technical College spending habits, and the imbalanced state of Milwaukee County's adult mental health system. This year's list is equally diverse and provocative (or so we hope). Without further ado, here they are in chronological order:

1. Greater Milwaukeeans need to be better educated about how their individual actions impact regional water quality. Our January report detailing results of a survey of 400 area residents on water-related issues revealed that nearly 85% feel "the actions of individuals do not have an impact on water quality and quantity problems," while only 4% feel they "have a responsibility to future generations to protect the region’s water resources." Those responses may be linked to the survey's additional finding that respondents place a relatively low value on water quality as a factor in the regional economy, and suggest that stepped up public education efforts are in order, particularly if the region's status as a freshwater innovator is to be promoted.


2. MMSD's capital spending needs are daunting and may conflict with the capital needs of other local governments. Our comprehensive fiscal assessment of the Metropolitan Milwaukee Sewerage District (MMSD) - released in June - found a local governmental body that is in sound fiscal condition. Nevertheless, despite the completion of deep tunnel expenditures and expiration of stipulation agreements with federal and state regulators, "the types of enormous capital investments that distinguish MMSD from other local governments...may need to continue because fundamental water pollution problems remain." We caution that in light of their enormity, MMSD’s capital priorities may need to be debated in the context of the investment needs faced by other local governments for schools, parks, roads, libraries, etc.


3. Milwaukee County was housing or paying for an average of 556 fewer adult and juvenile inmates per day at the end of 2010 than it was at the end of 2008. In a June research brief, we documented the remarkable decline in the county's inmate population and speculated on possible causes. We also calculated related financial savings, estimating the county spent $12 million less on adult and juvenile incarceration in 2010 than it did two years earlier. The brief noted that while some county law enforcement officials disagreed on the public safety impacts of reduced inmate populations, the county's fiscal woes demanded consideration of strategies to sustain the downward trends.


4. Analysis of the budgets of 15 comparable cities shows Milwaukee is the only one funded substantially with intergovernmental revenue. While the Forum has consistently reported on Milwaukee's significant reliance on state government, even we were surprised at the extent of that reliance when compared to other cities. A July report by the Forum's 2010-11 Norman N. Gill fellow found that the 15 comparison cities use intergovernmental revenue to fund about 18% of their budgets, as compared to Milwaukee's 46%. Meanwhile, at least half of every other city’s budget is funded by local tax revenue, with most having access to a local sales or income tax to supplement property tax funding.


5. Strategic economic development planning is a national trend that has not yet taken hold in Milwaukee. "Assembling the Parts," our November report on Milwaukee's economic development landscape, noted that while impressive progress has been made by city and private sector leaders to assemble the right pieces of a comprehensive economic development strategy, the city still could benefit from a strategic vision and plan that ties those pieces together into a "cohesive and strategically organized whole." We cited the existence of such plans in other cities and discussed a new "metropolitan business planning" concept engineered by the Brookings Institute that could provide great value to Milwaukee.

With 20 research reports in 2011, it was not easy for us to narrow down our list of top findings to five. Left off the list this year were important findings related to the readiness of area child care providers for the state's new quality ratings system; the impacts of the state budget repair bill on Milwaukee's city and county budgets; the views of area residents on municipal shared services and consolidation; and the potential for greater collaboration in technology transfer among local universities. Those interested in reviewing those and other findings can check out our full list of research publications here.

Does Milwaukee County have a bigger role to play in economic development?

On its face, the recent announcement that Wauwatosa mayor Jill Didier is leaving office to become Milwaukee County's new Economic Development Coordinator is promising news on the economic development front.

As a former mayor, Didier obviously has strong connections to area business and municipal leaders, which should bolster the county's economic development activities.

In addition, the specific jurisdiction over which she presided is key. Wauwatosa is home to the Milwaukee County Grounds, which houses the county's Parks Department, Behavioral Health Division, and Juvenile Justice Center, as well as the Regional Medical Center. As the Forum has suggested in previous reports, determining the county's appropriate ownership of land and buildings on the County Grounds in light of the land's value, and within the context of its diminished workforce and fiscal challenges, should be a major priority for policymakers. The new Economic Development Coordinator's familiarity with those properties and County Grounds tenants could be quite helpful in that regard.

The Forum also is pleased to see that another research finding recently trumpeted in our Assembling the Parts report - that greater coordination is needed between metro Milwaukee's impressive array of economic development initiatives and players - has been cited in connection with Didier's appointment. As reported in the Business Journal Serving Greater Milwaukee, the county's Economic Development Director cited that finding and said the new coordinator position - as well as Didier's appointment to it - reflect the county's intention of playing an important role in such coordination.

A word of caution may be in order, however, in light of another finding from Assembling the Parts. In examining the role that Milwaukee County traditionally has played in economic development, we note that its tools and resources are rather limited, which explains its limited activities in this area. Unlike other economic development players, for example, the county cannot grant tax incentives or credits to businesses; has little access to real estate or business financing; and can't create tax incremental districts. Consequently, its traditional role has centered primarily on managing and marketing its own real estate.

The coordination and "cheerleading" role envisioned by county leaders takes the county in a new and expanded direction and may prove to be very beneficial, particularly in light of Mayor Didier's background and connections. The only question is whether an entity that lacks economic development tools will command the respect needed to coordinate the region's players, and whether such an entity can truly make a difference in business attraction and retention efforts.

In light of the region's pressing economic development needs, it is difficult to fault county leaders for trying to carve out a larger role for themselves in the region's economic development landscape. As they do so, however, they may wish to keep in mind our Assembling the Parts warning that their efforts "not simply duplicate, but rather strategically complement, those conducted by other players."

Priority-setting at the Milwaukee County Courthouse

In the Public Policy Forum's annual review of the Milwaukee County Recommended Budget - released this morning - we commend the administration’s efforts to establish clear priorities and make difficult decisions, but emphasize there is “still much work to be done” to address the county’s structural imbalance.

Clearly, this is a budget that does not shy away from difficult spending cuts, ranging from elimination of support for the Emergency Medical Services (EMS) program and local arts groups, to substantial reductions in the Office of the Sheriff, to another sweeping call for health care savings from county workers. We caution that while the programmatic impacts and consequences of those decisions must be carefully deliberated, the county executive and his budget staff deserve credit for recognizing the need to cut somewhere.

Despite several positive strides in the budget to address the county’s structural problems, the report notes that significant challenges remain. It points out that the use of reprogrammed federal funds to avert substantial bus service reductions is a two-year solution at best, and that the county’s continued reliance on annual wage freezes and health care cuts as primary budget-balancing tools may not be sustainable.

In addition, the report cites the county’s glaring lack of reserves – an issue exacerbated by a recommendation to diminish its contingency fund – as giving pause to any notion that it has fully reconciled its fiscal shortcomings, or that 2012 will be the first year in recent memory devoid of the need to debate mid-year corrective actions to avoid running a deficit.

The report concludes by noting that debate is needed regarding the priorities and strategies selected in the recommended budget, as well as the “appropriate mix of revenue enhancements and spending cuts.” It says it is imperative, however, for the county board to follow the budget’s example of making difficult decisions and avoiding short-term gimmicks.

The full report can be accessed here. The Forum released a similar review of the 2012 City of Milwaukee budget on Friday.

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.

Economic development strategies in Milwaukee County: E pluribus unum?

Milwaukee County Executive Chris Abele recently named Brian Taffora as Milwaukee County’s new director of economic development. According to the press release, the new director will be responsible for achieving Abele’s economic development priorities as well as several larger goals.

Two of the specific priorities, as one might expect, involve job creation in the Park East and further job growth within the County Grounds in Wauwatosa—both county-owned properties. More generally, however, the new director indicated that he will focus on the creation of partnerships among municipalities, universities, trade groups, and businesses located in the county in order to retain and grow existing businesses and increase new employment and economic opportunities.

An upcoming report by the Public Policy Forum on economic development goals and activities in Milwaukee will indicate that the new director is entering an economic development landscape well-populated by a variety of municipal agencies, public corporations, regional partnerships, and non-profit organizations. All of these entities cite a variety of economic development initiatives in which they are engaged. In fact, many of the economic development activities mentioned by Mr. Taffora are being undertaken, at least partially, by these other economic development participants.

If the county intends to increase its economic development efforts, as the county executive and his new economic development director seem to indicate, several questions should be considered at the outset.

First, what specific strategies will the county use to recruit or expand businesses in the area and how will these strategies complement the current strategies used by municipalities in the county? Second, if county government wants to increase economic development-based partnerships within the county, how will its efforts complement—or differ from—regional economic development organizations such as the Milwaukee 7? Third, what role will the county play when economic development disagreements arise between municipalities in the county such as the recent dispute over the potential relocation of Eaton Corporation? And finally, what economic development tools does the county have at its disposal that might advance regional priorities?

As the region emerges from an extended economic downturn there is little doubt that increased efforts, like those of the county, are needed. However, with such a variety of economic development efforts occurring in southeastern Wisconsin, perhaps the next question for the entire region is how to achieve greater coordination and prioritization among participants.

For example, as strategies change and new organizations form, would the region benefit from an economic development plan that explicitly states, for the public and the organizations themselves, what role each group will play? Stay tuned for the Forum’s forthcoming economic development report—tentatively scheduled for release in late summer—for detailed analysis of this and other strategic economic development questions facing our region.

Milwaukee County's declining corrections population

With all of the doom and gloom surrounding the finances of Milwaukee County government, it is certainly worthy of attention when some promising fiscal news emerges from the Courthouse. Consequently, when the Public Policy Forum learned that the inmate population at the county's two adult detention facilities had plummeted, we took notice.

In researching the matter, we found that not only had the adult population declined in recent years, but the number of delinquent youth housed in state corrections institutions had dropped even more dramatically. And, upon investigating the dollar savings associated with these declining populations, we found even more eye-opening numbers.

Today, the Forum published a Research Brief documenting the steep drop in Milwaukee County detention populations and spending. In addition to laying out the numbers, we recommend actions by county leaders to determine why these trends are occurring, how they are impacting public safety, and what might be done to sustain them. Among the report's key findings:

• The average number of adults and juveniles in detention each day was 2,892 in 2010, by far the lowest total in the past five years, and 16% lower than the average of 3,448 detainees held each day in 2008.


• On the juvenile detention side, the average daily population (ADP) of Milwaukee County youth housed in state juvenile corrections institutions was 170, or 35% lower than the average of 263 just two years earlier. In addition, the ADP in the county’s own juvenile detention facility decreased 17% in that period (from 106 to 88), and the monthly average of active cases in the juvenile system plummeted 39% (from 2,971 to 1,823).


• On the adult side, the total number of individuals under detention and/or the supervision of the Milwaukee County Sheriff declined by 455 between 2007 and 2010, a 14% decrease.


• The reductions in detainee populations have been major contributors to substantial property tax levy reductions in the budgets of both the county’s Delinquency and Court Services Division (DCSD) and Office of the Sheriff. At DCSD, property tax levy expenditures decreased from $19.8 million to $12.8 million between 2008 and 2010, while property tax expenditures on adult detention in the Sheriff’s budget decreased from $101 million to $97 million during the same period.

The Research Brief explains that there are several competing points of view among law enforcement officials and others as to why the steep declines in detainee populations are occurring and whether they are desirable from a public safety perspective. Because of these competing views and a lack of available data to determine who is correct, the report recommends a series of actions by elected and justice system officials to step up data collection efforts and solicit informed discussion.

In particular, this is the type of issue that should be carefully deliberated by the Milwaukee County Board of Supervisors. In a 2010 report on the county's governance structure, the Forum observed that other county boards tend to place "greater focus on nuts-and-bolts administrative strategies – how to more effectively reduce jail populations, process individuals through the courts, achieve higher bond ratings, fill potholes – and less on ideological debate."

The decline in detention populations, therefore, not only gives supervisors a great opportunity to save money, but also to undertake the type of rigorous policy oversight that ought to be a norm at committee meetings and budget hearings.

The Research Brief - which was made possible by grant funding from the Helen Bader Foundation - can be accessed here, and our media release here.

Are Milwaukee County's child care providers ready for YoungStar?

New results from a statewide survey of 1,425 child care providers show that Milwaukee County providers compare favorably to providers across the state with respect to several measures that will be rewarded under the state's new YoungStar child care rating system.

The survey, conducted by the Forum in partnership with the Wisconsin Early Childhood Association, was designed to provide a picture of the status of the early childhood workforce in the state. Provider characteristics such as educational attainment, experience, professional credentials, and salary were measured. Providers were also given a chance to express their opinions about the new rating system.

Key findings include:

• The 223 respondents from Milwaukee County demonstrate higher educational attainment and earned professional credentials than their colleagues statewide, factors that can earn a provider a higher rating under YoungStar.


• Providers in Milwaukee County appear to enjoy greater access to professional development than providers elsewhere in the state, via higher rates of membership in professional associations and use of scholarship and stipend programs.


• Providers in Milwaukee County have higher median wages than the state as a whole and have higher child care subsidy usage rates. Not surprisingly, Milwaukee County providers also charge higher fees.


• Child care centers in Milwaukee County are more likely to be accredited. Accreditation can mean a center automatically receives the highest rating under YoungStar.


• Milwaukee County providers are more likely to see YoungStar as an opportunity to improve the quality of their early childhood programming than providers statewide.

For the full report, visit the Forum's website.

The cruel world of local government finance

In the weeks since release of the governor's proposed 2011-13 state budget, much has been spoken and written about the potential impacts of cuts in state aids on local government budgets and services. Yet, while much of the discussion has focused on high-profile cuts to shared revenues, municipal recycling grants and general transportation aids, buried within the budget are dozens of less-publicized, complicated provisions that also may have far-reaching impacts.

One of those relatively obscure provisions is related to the new property tax levy limit on municipal and county governments. The limit itself has received considerable attention, as instead of having their annual allowable property tax growth capped at no lower than 3%, counties and municipalities would be capped at the greater of 0% or the percentage growth in equalized value resulting from new construction. Because the change in new construction is projected to be less than 1% in many counties and municipalities, that's a significant reduction.

But perhaps equally noteworthy is a provision that would require counties and municipalities to decrease their allowable levy in any year in which they experience a decrease in debt service on debt issued before July 1, 2005, by an amount equal to the decrease. In other words, if a local government is fortunate enough to experience a lower overall debt service payment from one year to the next, then instead of having the discretion to do as it pleases with those savings, it may be required to pass the savings back to its property taxpayers.

Without taking up the issue of whether the new provision is good or bad for those taxpayers, it does throw a curveball at those local governments that have consciously tried to keep a lid on their debt issuances as a strategy for obtaining long-term operating budget relief.

One such government is Milwaukee County. Despite the county's overall budget woes (as documented in several reports by the Public Policy Forum and others), one of its true fiscal success stories has been in the area of debt management. Just last month, for example, the Standard & Poor's ratings agency praised the county for its "moderate debt burden with rapid debt amortization."

As we explained in our recent Milwaukee County Executive Election Brief, after it decided to refinance a major portion of its debt in 2003, the county made a concerted and deliberate effort to keep a lid on annual borrowing. In fact, its discipline in adhering to self-imposed caps on general obligation bonding, while arguably contributing to its vast backlog of infrastructure needs, has positioned the county to benefit from a significant decrease in annual debt service payments by 2015. In that year, according to the county's 2011 budget, the annual debt service payment could drop from $63 million to $47 million.

Until recently, county fiscal officials viewed the funds freed up from potential reduced debt payments as a critical piece of a long-term approach to dissolving the county's structural deficit. In fact, given the painful nature of all other potential strategies, this was one of the few bright spots in the county's long-term fiscal picture.

If the new requirement that local governments reduce their levies commensurate with reductions in annual debt service payments is adopted, however, then one of the only promising tools in Milwaukee County's limited deficit-reduction toolbox will be eliminated. Such is the world of local government finance, where even the best laid plans can be wiped out by higher levels of government at a moment's notice.

Framing the issues for the county executive candidates

During the past three years, the Public Policy Forum has churned out more than a half-dozen reports on issues pertaining to Milwaukee County government as part of our mission to educate the public about key policy issues impacting the region's economy and quality of life.

Those include an award-winning report on the county's transit funding crisis; a comprehensive review of the fiscal condition of its parks system and cultural facilities; another award-winning assessment of its overall fiscal condition; a redesign plan for its adult mental health system; and a carefully-researched analysis of potential substantive changes to its governance structure.

Today, we release a 2011 Milwaukee County Executive Election Brief that describes and frames those issues in a manner designed to be comprehensible to voters and helpful to the candidates themselves. The report begins with an overview of Milwaukee County’s budget and finances that provides a broad sense of the county’s budgetary structure and its longstanding fiscal challenges. Then, it summarizes and updates our recent research on the structural deficit, mass transit, mental health, and parks/recreation/culture. Each section concludes with a set of questions and policy considerations that should be foremost in the minds of candidates and voters.

Our goal, as always, is to cut through the politics and boil down these controversial issues to their basics. Doing so shows that in many respects, the issues and problems facing Milwaukee County government are elementary in nature and demand equally elementary, yet politically difficult, responses. Our hope is that the candidates will acknowledge the relatively uncomplicated roots of the county's challenges and candidly discuss their proposed solutions.

The full report can be accessed here. Also, tomorrow's the last day to sign up here for our February 4 county executive candidates forum, at which the report will be discussed.

Some good news from Milwaukee County's mental health complex

While the problems experienced by Milwaukee County's Behavioral Health Division (BHD) justifiably receive considerable attention in the local news media, there also are some shining success stories that seldom are reported.

One obvious example is the division's Wraparound Milwaukee program for children with complex mental health and emotional needs, which received an "innovations" award from Harvard's Kennedy School of Government in September 2009. Another - discussed recently in a report submitted to the county's Health and Human Needs Committee - is its WIser Choice program for individuals suffering from substance abuse.

WIser Choice was created by BHD and the state after they were awarded a three-year, $22 million federal Access to Recovery (ATR) grant in 2004. The grant funds gave BHD the resources to transform its substance abuse program into one that provides a comprehensive blend of recovery-oriented services. Those services extend beyond traditional drug and alcohol treatment to also include pre-employment education/training, transportation, housing, life skills training and other supports. The county and state successfully collaborated on a second three-year ATR award in 2007 and recently received federal approval for a third three-year installment.

The program's success in competing for scarce federal funds is a direct reflection of its impressive client outcomes. In fact, according to BHD, those outcomes - based on national measures established as part of ATR - generally have been the best of any ATR grantee. Also, in the 2002-2004 pre-WIser Choice period, Milwaukee had the highest rate (13.47%) of any urban area in the nation of persons with a past-year substance use disorder. From 2006-2008, however, Milwaukee’s rate dropped to 9.96%, which ranks it only 22nd among urban areas.

Recently released federal data also show the following impressive results:

• Milwaukee dropped from 1st among urban areas to 7th in binge drinking.


• Milwaukee dropped from 2nd to 20th among urban areas in past-year treatment gap for alcohol use disorders.


• Milwaukee’s rate of substance use disorders dropped 20.1% from 2004 to 2008, while the nation’s rate as a whole decreased only 1.8%.

The success of Wraparound and WIser Choice has relevance to efforts to address the serious problems plaguing BHD's adult mental health operations. A report released in October by the Forum and Human Services Research Institute argues for a redesign of those operations, highlighted by a much greater emphasis on community-based services and a gradual downsizing of the county's role in inpatient and long-term care. A few of the encouraging lessons from Wraparound and WIser Choice that might inspire the adult mental health redesign effort:

1. BHD has shown that with sufficient resources and appropriate support from elected officials, it is fully capable of designing and implementing successful models of behavioral health care and treatment.


2. BHD and the Wisconsin Department of Health Services have shown they can put the politics of their elected leaders aside to collaborate effectively and bring additional federal resources to Milwaukee County.


3. BHD has deftly created and managed relationships with community-based providers in both programs to achieve results that benefit both clients and taxpayers.

Good news from Milwaukee County’s mental health complex may be rare, but in this case it should provide hope for the future.

PPF's top research findings of 2010

The Forum recently received a communication from a national research group detailing its top five findings this year. That got us to thinking about our top five research findings of 2010. The competition was stiff, but here they are, in chronological order (drum roll please):

1. Southeast Wisconsin's skilled workforce may be its greatest economic strength. Our March Innovation Index report benchmarked our region with three Midwestern peers and three innovation leaders using several indicators linked to success in building a knowledge-based economy. While the overall assessment was mixed, we found southeast Wisconsin was number one among the group in its percentage of residents working in middle-skill jobs, i.e. those that require specialized training or education beyond a high school diploma, but less than a four-year degree. The finding suggests that while our region may be lacking in college graduates, we still possess the type of workforce that should be very attractive to certain industries.


2. Milwaukee County's structural deficit is really, really daunting. In our July preview of the county's 2011 budget, we used the county's fiscal forecasting tool to determine how its five-year fiscal outlook would change under two relatively dramatic scenarios: 1) the property tax increased at double the projected growth rate, or 6.6% per year, for each of the next five years; or 2) projected growth in salaries and fringe benefits was reduced by 50% and 25% respectively in each of the next five years. We found that in both cases, the projected structural deficit in 2016 still would be in the range of $65 to $70 million. Quite a challenge, indeed, for the next county executive.


3. MATC clearly spends more than its peers. Our September fiscal assessment of the Milwaukee Area Technical College found an institution struggling to accommodate shrinking revenue streams at the very time that demand for its services had reached historic highs. While plummeting property tax capacity and shrinking state revenues certainly hurt, however, it appears there is capacity to make adjustments to the expenditure side of MATC's ledger. Our research compared MATC with 84 other large two-year technical and community colleges nationally with regard to total operating expenses, salary expenditures and fringe benefit expenditures. We found that MATC ranks number one in expenditures per full-time-equivalent student on each of those measures.


4. Milwaukee County's mental health system is out of balance. Our October report on mental health care for adults in Milwaukee County - released jointly with the Human Services Research Institute - found a system that is out of sync with national trends and best practices in light of its emphasis on inpatient care and its lack of comprehensive community-based services. Particularly telling was a finding that the county's 472 public and private acute inpatient beds are nearly triple the number that would be expected in a mature mental health system that contains the appropriate balance of inpatient, crisis and community-based services.


5. The state's expensive child care subsidy program has grown as household incomes have shrunk. When the state created the Wisconsin Shares child care subsidy program in 1996, all low-income families became eligible, not just former welfare recipients. Participation has grown nearly 350% since then, in part because of a decline in household incomes. Whereas the program's eligibility limit of 185% of federal poverty line represented 57% of the state median income in 1999, today it equals 68%. As we point out in a December report, this trend does not bode well for the state’s new child care quality ratings system initiative, as a continued decline in household incomes may mean continued growth in program enrollment. That, in turn, could translate into less money available to offer incentives to providers for quality improvements.

Narrowing the list to five wasn't easy. We were forced to leave out additional key findings from reports on the Milwaukee Parental Choice Program, the region's public schools, regional property values and taxes, the City of Milwaukee's Main Street Milwaukee program, and three People Speak surveys, among others. Each of the 20 reports the Forum has published so far this year can be accessed here.

Is bankruptcy really an option?

The politicization of a recent disclosure that a leading civic organization has discussed potential bankruptcy for Milwaukee County is not surprising. But putting aside the politics, shouldn't we be asking whether, from a government finance perspective, bankruptcy is a realistic or viable option for the county?

A recent article on the Governing website examined the question of whether we're likely to see a surge in government bankruptcies nationally. It found the answer, generally speaking, to be "no." The article features excerpts from an interview with Robert A. Kurtter, a senior public finance official from Moody's credit rating agency. Among the points in the article that are relevant to Milwaukee County's situation:

• Local governments across the country clearly are being squeezed and facing agonizing decisions regarding whether to cut services, raise taxes, or both. Nevertheless, the specter of bankruptcy typically is tossed around as a rhetorical tool, as opposed to a legal one. As Kurtter puts it, "There may be talk about governments being bankrupt and insolvent when what is meant is 'We don't want to raise taxes and don't want to spend so we have to cut.'"


• Municipal bankruptcies typically occur when governments no longer can afford payments on their debt. Kurtter expects defaults at a higher rate than after previous recessions, but they should continue to be "rare and idiosyncratic," and likely will be linked to huge capital projects (like incinerators or steam plants) that "went bad."


• When the city of Vallejo, California, resorted to bankruptcy three years ago to seek relief from unaffordable union contracts, many thought it would set off a wave of similar filings. That hasn't happened, according to Kurtter, because "municipal bankruptcy is expensive, it's time consuming and the outcome is not at all clear...governments understand they need to figure out how to balance budgets and deliver essential public services now."

The Public Policy Forum has not minced words in our assessment of Milwaukee County's financial situation. In a July report, we cited the county's own projection of a $100 million structural deficit by 2014 and called its long-term budget prognosis "alarming." And, in a March 2009 report, we stated that "while the county enjoys cash solvency and a reasonable debt service level, annual reductions have not achieved financial equilibrium, and the county's fiscal condition remains highly unstable."

Still, we have suggested that despite its deep structural imbalance, the county's fiscal woes stem mostly from a lack of political consensus on how to plan for and manage its financial challenges. That reality - combined with the county's continued strong capital debt management, its huge inventory of physical assets, the fact that it is tens of millions of dollars below its state-imposed property tax levy cap, and the uncertainties regarding bankruptcy's legality and its impacts on critical county services - makes it difficult to imagine a bankruptcy declaration any time soon.

A budget marked by uncertainty

The Public Policy Forum's annual analysis of the Milwaukee County recommended budget - released this morning - focuses on the significant wage and benefit concessions that allow the county executive to bridge the county's annual structural gap while averting major service cuts and revenue increases.

The analysis emphasizes the necessity of stringent controls on wages and deep cuts in benefits given the county's ominous fiscal challenges, and gives particular credit to the budget's creative attempt to rein in the lucrative free health care benefit provided to retirees hired prior to 1994. While noting the appropriateness of these measures as a strategic direction for the county, however, it suggests there is considerable risk in plugging the savings into the budget in light of the need for collective bargaining and questions surrounding the timing of implementation.

A key theme of this year's budget brief, in fact, is the uncertainty surrounding several areas of major savings in the recommended budget and the potential consequences should they not come to fruition. We update three models used in our July budget preview report to give readers a sense of the types of options available to the county if it is faced with a sizable mid-year gap, while also pointing out some key policy considerations regarding the potential for another 26 furlough days for 1,700 union workers and up to 165 union layoffs.

The 2011 Milwaukee County Budget Brief can be accessed here. The Forum released a similar analysis of the 2011 City of Milwaukee budget earlier this week, which can be accessed here.

A new strategic direction for mental health care in Milwaukee County

A recent series of articles in the Milwaukee Journal Sentinel on safety issues at Milwaukee County's Mental Health Complex is the latest to raise questions about the level and quality of mental health care in our community. Unfortunately, while these exposes have ranked high in shock value, they have yet to produce the comprehensive redesign of the public and private mental health systems that many feel is needed.

A report released today may provide the impetus for such change. The report - authored by Massachusetts-based Human Services Research Institute - culminates a two-year project initiated by the Milwaukee Health Care Partnership (a collaboration headed by the five major health systems in Milwaukee County), the Medical Society of Milwaukee County, and the Milwaukee County Behavioral Health Division. The project’s objective was to bring in national expertise to examine gaps in the existing adult mental health care delivery system and devise ways to transform that system into one that more closely mirrors national best practices. The Public Policy Forum has served as local facilitator for the project.

Readers of the report should be forewarned - in many respects, this is a technical document that contains dozens of pages of data findings and analysis and lots of references to mental health policies and practices that may not be familiar to the average citizen.

But that also may be its strength. Indeed, by suggesting a new strategic direction based on data and facts, it is hoped that this report can de-politicize and de-sensationalize a set of complex issues and challenges that must be confronted for the sake of the overall health of our community and the fiscal health of Milwaukee County government.

Some of the report's recommendations may be controversial, and some may require new fiscal resources (though the report emphasizes re-directing existing dollars, as opposed to finding new ones). Implementing those recommendations will not be easy, and will require teamwork and cooperation from several levels of government, law enforcement, consumers, advocates, community-based organizations, and private sector payers and providers. Yet, the diversity of the stakeholders group that has brought the project this far certainly provides hope.

The media release accompanying the report - which provides additional details about the project's history and the stakeholders that have guided it - can be accessed here. The executive summary and full report can be accessed here and here.